Provider Demographics
NPI:1619841038
Name:AUTHENTIC LIVING LAB LLC
Entity type:Organization
Organization Name:AUTHENTIC LIVING LAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:DELSONDRA
Authorized Official - Middle Name:JONELL
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:LISW- CP
Authorized Official - Phone:803-714-3774
Mailing Address - Street 1:9600 TWO NOTCH RD
Mailing Address - Street 2:SUITE 5 # 1285
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-1612
Mailing Address - Country:US
Mailing Address - Phone:803-714-3774
Mailing Address - Fax:
Practice Address - Street 1:220 OLDE SPRINGS RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-1612
Practice Address - Country:US
Practice Address - Phone:803-714-3774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-30
Last Update Date:2025-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty