Provider Demographics
NPI:1205473329
Name:LIFE ENHANCED COUNSELING SERVICES
Entity type:Organization
Organization Name:LIFE ENHANCED COUNSELING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TONYETTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:ROSS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, CSAC, ICAADC,
Authorized Official - Phone:414-690-0672
Mailing Address - Street 1:1711 W CLAYTON CREST AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53221-3830
Mailing Address - Country:US
Mailing Address - Phone:414-690-0672
Mailing Address - Fax:
Practice Address - Street 1:5330 W VILLARD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4345
Practice Address - Country:US
Practice Address - Phone:414-690-0672
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health