Provider Demographics
NPI:1134581580
Name:BACK TO LIFE COUNSELING, LLC
Entity type:Organization
Organization Name:BACK TO LIFE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:PACKARD
Authorized Official - Suffix:
Authorized Official - Credentials:CAC III
Authorized Official - Phone:303-651-2554
Mailing Address - Street 1:500 9TH AVE STE 10
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-4599
Mailing Address - Country:US
Mailing Address - Phone:303-651-2554
Mailing Address - Fax:303-485-2477
Practice Address - Street 1:500 9TH AVE STE 10
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-4599
Practice Address - Country:US
Practice Address - Phone:303-651-2554
Practice Address - Fax:303-485-2477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1751-01251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health