MEDICARE: FAMILY LIFE COUNSELING CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1215509005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY LIFE COUNSELING CENTER

Provider Business Mailing Address
First Line	:	1230 OAKLEY SEAVER DR STE 307
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-1961
Country	:	US
Telephone Number	:	352-988-6673
Fax Number	:

Provider Business Practice Location Address
First Line	:	4484 N JOHN YOUNG PKWY
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32804-1939
Country	:	US
Telephone Number	:	352-988-6673
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DAMARIS REVERON
Credential	:
Telephone Number	:	352-988-6673

Provider Enumeration Date	:	07/12/2021
Last Update Date	:	07/12/2021

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Directions to “FAMILY LIFE COUNSELING CENTER ” Practice Location

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