Provider Demographics
NPI:1053977348
Name:LIFE RESTORE COUNSELING & TRAINING, LLC
Entity type:Organization
Organization Name:LIFE RESTORE COUNSELING & TRAINING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PROFESSIONAL COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:GINGLES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:318-573-2133
Mailing Address - Street 1:2223 OLD MINDEN RD STE C3
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-2303
Mailing Address - Country:US
Mailing Address - Phone:318-573-2133
Mailing Address - Fax:
Practice Address - Street 1:2223 OLD MINDEN RD STE C3
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-2303
Practice Address - Country:US
Practice Address - Phone:318-573-2133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty