Provider Demographics
NPI:1922430628
Name:LIFETIME COUNSELING LLC
Entity Type:Organization
Organization Name:LIFETIME COUNSELING LLC
Other - Org Name:LIFETIME COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / ORGANIZER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:NEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:678-425-9007
Mailing Address - Street 1:138 PARK AVE
Mailing Address - Street 2:SUITE 214
Mailing Address - City:WINDER
Mailing Address - State:GA
Mailing Address - Zip Code:30680-2118
Mailing Address - Country:US
Mailing Address - Phone:678-425-9007
Mailing Address - Fax:678-425-9009
Practice Address - Street 1:138 PARK AVE
Practice Address - Street 2:SUITE 214
Practice Address - City:WINDER
Practice Address - State:GA
Practice Address - Zip Code:30680-2118
Practice Address - Country:US
Practice Address - Phone:678-425-9007
Practice Address - Fax:678-425-9009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-05
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC006641251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003133270AMedicaid