Provider Demographics
NPI:1174115539
Name:LIFE POURED OUT SERVICES, INC.
Entity type:Organization
Organization Name:LIFE POURED OUT SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/CO-FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUZETT
Authorized Official - Middle Name:DELICIA
Authorized Official - Last Name:BLOUNT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:718-644-4998
Mailing Address - Street 1:3595 HIRAM DOUGLASVILLE HWY STE 108
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-4963
Mailing Address - Country:US
Mailing Address - Phone:770-635-7847
Mailing Address - Fax:910-516-1336
Practice Address - Street 1:3595 HIRAM DOUGLASVILLE HWY STE 108
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-4963
Practice Address - Country:US
Practice Address - Phone:770-635-7847
Practice Address - Fax:910-516-1336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GALPC011523OtherPROFESSIONAL