Provider Demographics
NPI:1720223274
Name:CHOOSING HOW I LIVE LIFE OUTPATIENT SERVICES
Entity Type:Organization
Organization Name:CHOOSING HOW I LIVE LIFE OUTPATIENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOER
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCDC
Authorized Official - Phone:512-385-4799
Mailing Address - Street 1:1700 MONTOPOLIS DR STE D
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78741-5138
Mailing Address - Country:US
Mailing Address - Phone:512-385-4799
Mailing Address - Fax:
Practice Address - Street 1:1700 MONTOPOLIS DR STE D
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-5138
Practice Address - Country:US
Practice Address - Phone:512-385-4799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-12
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1920-1920 A101YA0400X
320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX065483201Medicaid