Provider Demographics
NPI:1578979027
Name:SOTM LIFE SKILLS CENTER, LLC
Entity Type:Organization
Organization Name:SOTM LIFE SKILLS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:972-709-1180
Mailing Address - Street 1:549 W WHEATLAND RD
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75116-4515
Mailing Address - Country:US
Mailing Address - Phone:972-709-1180
Mailing Address - Fax:972-709-1180
Practice Address - Street 1:549 W WHEATLAND RD
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-4515
Practice Address - Country:US
Practice Address - Phone:972-709-1180
Practice Address - Fax:972-709-1180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-05
Last Update Date:2014-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX66598101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3286940Medicaid