Provider Demographics
NPI:1336166040
Name:LIFELINE COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:LIFELINE COUNSELING CENTER LLC
Other - Org Name:JAMES W. & NANCY L. DAVIDSON
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:WILSON
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:440-942-0100
Mailing Address - Street 1:4212 STATE ROUTE 306
Mailing Address - Street 2:SUITE 306
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44094-9258
Mailing Address - Country:US
Mailing Address - Phone:440-942-0100
Mailing Address - Fax:877-581-3908
Practice Address - Street 1:4212 STATE ROUTE 306
Practice Address - Street 2:SUITE 306
Practice Address - City:WILLOUGHBY
Practice Address - State:OH
Practice Address - Zip Code:44094-9258
Practice Address - Country:US
Practice Address - Phone:440-942-0100
Practice Address - Fax:877-581-3908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2011-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2071103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHDACP15801Medicare PIN
OHDACP07702Medicare PIN
OH9273751Medicare PIN