Provider Demographics
NPI:1699551507
Name:LEAVE YOUR MARK LIFE COACHING
Entity type:Organization
Organization Name:LEAVE YOUR MARK LIFE COACHING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMFT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICKOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:757-493-1514
Mailing Address - Street 1:762 INDEPENDENCE BLVD STE 786
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6200
Mailing Address - Country:US
Mailing Address - Phone:757-493-1514
Mailing Address - Fax:
Practice Address - Street 1:762 INDEPENDENCE BLVD STE 786
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6200
Practice Address - Country:US
Practice Address - Phone:757-493-1514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty