Provider Demographics
NPI:1588178487
Name:NNK 4 LIVING INDEPENDENTLY FOR EXCELLENCE (L.I.F.E.)
Entity Type:Organization
Organization Name:NNK 4 LIVING INDEPENDENTLY FOR EXCELLENCE (L.I.F.E.)
Other - Org Name:NNK 4 L.I.F.E.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:N
Authorized Official - Last Name:BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-561-3091
Mailing Address - Street 1:3826 SALEM RD # 136
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30016-4528
Mailing Address - Country:US
Mailing Address - Phone:678-561-3091
Mailing Address - Fax:404-795-8974
Practice Address - Street 1:1194 147TH ST STE 5
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:GA
Practice Address - Zip Code:31064-8068
Practice Address - Country:US
Practice Address - Phone:678-561-3091
Practice Address - Fax:404-795-8974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8941101YA0400X, 101YM0800X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003181947AMedicaid
GA003181947JMedicaid