Provider Demographics
NPI:1558694372
Name:LIFE COUNSEING CENTER, INC
Entity Type:Organization
Organization Name:LIFE COUNSEING CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCPC
Authorized Official - Phone:208-465-5433
Mailing Address - Street 1:112 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-5011
Mailing Address - Country:US
Mailing Address - Phone:208-465-5433
Mailing Address - Fax:
Practice Address - Street 1:112 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-5011
Practice Address - Country:US
Practice Address - Phone:208-465-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-11
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID808318000Medicaid
ID808445101Medicaid