Provider Demographics
NPI:1689874851
Name:LIFE CHANGES COUNSELING SERVICES
Entity Type:Organization
Organization Name:LIFE CHANGES COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:LOQUITA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW
Authorized Official - Phone:704-451-8550
Mailing Address - Street 1:3611 MOUNT HOLLY HUNTERSVILLE RD
Mailing Address - Street 2:SUITE 344
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-8636
Mailing Address - Country:US
Mailing Address - Phone:704-451-8550
Mailing Address - Fax:828-286-4450
Practice Address - Street 1:668 WITHROW RD
Practice Address - Street 2:
Practice Address - City:FOREST CITY
Practice Address - State:NC
Practice Address - Zip Code:28043-9695
Practice Address - Country:US
Practice Address - Phone:828-286-4466
Practice Address - Fax:828-286-4450
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCCOO4782P1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002881Medicaid