Provider Demographics
NPI:1851517163
Name:LIFE ENRICHMENT COUNSELING CENTER, INC.
Entity Type:Organization
Organization Name:LIFE ENRICHMENT COUNSELING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:BEVERLEY
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BOOTHE-MOORING
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:703-754-0636
Mailing Address - Street 1:7230 HERITAGE VILLAGE PLZ
Mailing Address - Street 2:SUITE 202
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155-3053
Mailing Address - Country:US
Mailing Address - Phone:703-754-0636
Mailing Address - Fax:703-754-0646
Practice Address - Street 1:7230 HERITAGE VILLAGE PLZ
Practice Address - Street 2:SUITE 202
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-3053
Practice Address - Country:US
Practice Address - Phone:703-754-0636
Practice Address - Fax:703-754-0646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040059091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA187850OtherANTHEM #
MDNO730001OtherCAREFIRST
VA298447345OtherUBH #