1861625162 NPI number — FULL LIFE COUNSELING, PLLC

Table of content: (NPI 1861625162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861625162 NPI number — FULL LIFE COUNSELING, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FULL LIFE COUNSELING, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861625162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1066 W 4TH ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27101-2434
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-923-7426
Provider Business Mailing Address Fax Number:
704-625-3617

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1066 W 4TH ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27101-2434
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-923-7426
Provider Business Practice Location Address Fax Number:
704-625-3617
Provider Enumeration Date:
09/02/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MILLS
Authorized Official First Name:
VIRGINIA
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
336-923-7426

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  2943 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1639334022 . This is a "NPPES" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1467603704 . This is a "NPPES" identifier . This identifiers is of the category "OTHER".