Provider Demographics
NPI:1154198786
Name:FAMILY LIFE COUNSELING CENTER LLC
Entity type:Organization
Organization Name:FAMILY LIFE COUNSELING CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DUTY
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:208-407-8014
Mailing Address - Street 1:1159 E IRON EAGLE DR STE 170
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6870
Mailing Address - Country:US
Mailing Address - Phone:208-407-8014
Mailing Address - Fax:
Practice Address - Street 1:1159 E IRON EAGLE DR STE 170
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6870
Practice Address - Country:US
Practice Address - Phone:208-407-8014
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-05
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional