Provider Demographics
NPI:1245543370
Name:LIFE COACH PSYCHOLOGY
Entity type:Organization
Organization Name:LIFE COACH PSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:269-471-9892
Mailing Address - Street 1:9067 US HIGHWAY 31
Mailing Address - Street 2:SUITE 203
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1664
Mailing Address - Country:US
Mailing Address - Phone:269-471-9892
Mailing Address - Fax:
Practice Address - Street 1:9067 US HIGHWAY 31
Practice Address - Street 2:SUITE 203
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1664
Practice Address - Country:US
Practice Address - Phone:269-471-9892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010743103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION12920Medicare PIN