Provider Demographics
NPI:1669870697
Name:LIFETIME COUNSELING SERVICE & MANAGEMENT SERVICES
Entity type:Organization
Organization Name:LIFETIME COUNSELING SERVICE & MANAGEMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAFRANCINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS BRADFORD
Authorized Official - Suffix:
Authorized Official - Credentials:LICENSE MFT
Authorized Official - Phone:229-630-2691
Mailing Address - Street 1:PO BOX 2961
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31604-2961
Mailing Address - Country:US
Mailing Address - Phone:229-630-2691
Mailing Address - Fax:888-974-8762
Practice Address - Street 1:2905 BEMISS RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-7007
Practice Address - Country:US
Practice Address - Phone:229-630-2691
Practice Address - Fax:888-974-8762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-08
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMFT001200106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty