1477051654 NPI number — LIFE WITHIN COUNSELING GROUP, LLC

Table of content: (NPI 1477051654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477051654 NPI number — LIFE WITHIN COUNSELING GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE WITHIN COUNSELING GROUP, LLC
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:
1477051654
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
905 MCAFEE MEDICAL CIRCLE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEEBE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72012
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-712-3031
Provider Business Mailing Address Fax Number:
501-242-0820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
905 MCAFEE MEDICAL CIRCLE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEEBE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72012
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-712-3031
Provider Business Practice Location Address Fax Number:
501-242-0820
Provider Enumeration Date:
01/23/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
RITCHIE
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
DALE
Authorized Official Title or Position:
OWNER/THERAPIST
Authorized Official Telephone Number:
501-712-3031

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  P1412126 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: P1412126 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 183080795 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".