Provider Demographics
NPI:1699705459
Name:TREE OF LIFE CHRISTIAN COUNSELING AGENCY, LLC
Entity type:Organization
Organization Name:TREE OF LIFE CHRISTIAN COUNSELING AGENCY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:540-710-0520
Mailing Address - Street 1:PO BOX 42111
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22404-2111
Mailing Address - Country:US
Mailing Address - Phone:540-710-0520
Mailing Address - Fax:703-490-3544
Practice Address - Street 1:4936 SOUTHPOINT PKWY
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-2659
Practice Address - Country:US
Practice Address - Phone:540-710-0520
Practice Address - Fax:703-490-3544
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA831101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA258225000OtherMENTAL HEALTH OUTPATIENT
VA441462OtherOUT-PATIENT MENTAL HEALTH
VA010200113Medicaid
VA010276128Medicaid
VA005411041Medicaid