Provider Demographics
NPI:1659854081
Name:PRIME LIFE COUNSELING, LLC
Entity Type:Organization
Organization Name:PRIME LIFE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PRIMEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC, NCC, ATR
Authorized Official - Phone:316-655-1376
Mailing Address - Street 1:9350 E CORPORATE HILLS DR UNIT 780791
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67278-0100
Mailing Address - Country:US
Mailing Address - Phone:316-655-1376
Mailing Address - Fax:
Practice Address - Street 1:9350 E CORPORATE HILLS DR UNIT 780791
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67278-0100
Practice Address - Country:US
Practice Address - Phone:316-655-1376
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSLCPC2512Medicaid