Provider Demographics
NPI:1659466860
Name:CHRISTIAN LIFE COUNSELING LLC
Entity Type:Organization
Organization Name:CHRISTIAN LIFE COUNSELING LLC
Other - Org Name:CHRISTIAN LIFE COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MENGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-785-1008
Mailing Address - Street 1:12630 W NORTH AVE BLDG E
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-4626
Mailing Address - Country:US
Mailing Address - Phone:262-785-1008
Mailing Address - Fax:262-462-3187
Practice Address - Street 1:12630 W NORTH AVE BLDG E
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-4626
Practice Address - Country:US
Practice Address - Phone:262-785-1008
Practice Address - Fax:262-462-3187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty