Provider Demographics
NPI:1558879270
Name:LIFE RESTORATION COUNSELING & PSYCHOLOGICAL SERVICES
Entity Type:Organization
Organization Name:LIFE RESTORATION COUNSELING & PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAGLIONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-414-0754
Mailing Address - Street 1:6489 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1048
Mailing Address - Country:US
Mailing Address - Phone:248-709-3897
Mailing Address - Fax:248-828-6364
Practice Address - Street 1:525 E BIG BEAVER RD STE 201
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1363
Practice Address - Country:US
Practice Address - Phone:248-709-3897
Practice Address - Fax:248-828-6364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009751251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
103T00000XOtherTAXONOMY
MI1992124390OtherNPI
103T00000XOtherTAXONOMY