Provider Demographics
NPI:1609433291
Name:LIFE INTERRUPTED COUNSELING SERVICES
Entity Type:Organization
Organization Name:LIFE INTERRUPTED COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KESHIA
Authorized Official - Middle Name:DONUEL
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LPC
Authorized Official - Phone:980-404-1069
Mailing Address - Street 1:516 HIGHLAND RIDGE PT
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-5507
Mailing Address - Country:US
Mailing Address - Phone:980-322-3466
Mailing Address - Fax:877-766-6203
Practice Address - Street 1:4045 N TRYON ST STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206
Practice Address - Country:US
Practice Address - Phone:980-404-1069
Practice Address - Fax:877-766-6203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-20
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty