Provider Demographics
NPI:1063965242
Name:LIFE ABUNDANT CENTER
Entity type:Organization
Organization Name:LIFE ABUNDANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:WALL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:270-792-9683
Mailing Address - Street 1:1830 DESTINY LN
Mailing Address - Street 2:SUITE105
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-1087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1830 DESTINY LN
Practice Address - Street 2:SUITE105
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1087
Practice Address - Country:US
Practice Address - Phone:270-792-9683
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY34831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty