Provider Demographics
NPI:1134958820
Name:LIVING LIFE SUPPORTIVE SERVICES LLC
Entity type:Organization
Organization Name:LIVING LIFE SUPPORTIVE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:804-536-5066
Mailing Address - Street 1:20 E TABB ST STE 205
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-4560
Mailing Address - Country:US
Mailing Address - Phone:804-536-5066
Mailing Address - Fax:202-545-3413
Practice Address - Street 1:20 E TABB ST STE 205
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4560
Practice Address - Country:US
Practice Address - Phone:804-536-5066
Practice Address - Fax:202-545-3413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1912646142Medicaid