Provider Demographics
NPI:1609173889
Name:BRANCH OF LIFE, INC
Entity Type:Organization
Organization Name:BRANCH OF LIFE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BILLY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CORN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC,LMFT
Authorized Official - Phone:972-296-2676
Mailing Address - Street 1:8554 COUNTY ROAD 4023
Mailing Address - Street 2:
Mailing Address - City:KEMP
Mailing Address - State:TX
Mailing Address - Zip Code:75143-4354
Mailing Address - Country:US
Mailing Address - Phone:972-296-2676
Mailing Address - Fax:
Practice Address - Street 1:202 W CENTER ST STE F
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75116-3441
Practice Address - Country:US
Practice Address - Phone:972-296-2676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187018001Medicaid