Provider Demographics
NPI:1972123362
Name:LIFE SOURCE COUNSELING & CONSULTING, LLC
Entity type:Organization
Organization Name:LIFE SOURCE COUNSELING & CONSULTING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANE
Authorized Official - Middle Name:EVETTE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:404-372-8941
Mailing Address - Street 1:P.O. BOX 302
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-0302
Mailing Address - Country:US
Mailing Address - Phone:404-372-8941
Mailing Address - Fax:
Practice Address - Street 1:118 NORTH AVENUE, SUITE A
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236
Practice Address - Country:US
Practice Address - Phone:404-372-8941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)