MEDICARE: LIFESTYLE COUNSELING

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	101YM0800X	Mental Health Counselor	12824	FL

General Provider Information

NPI Number	:	1700287646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLE COUNSELING

Provider Business Mailing Address
First Line	:	70 6TH ST
Second Line	:
City	:	SHALIMAR
State	:	FL
Zip	:	32579-1362
Country	:	US
Telephone Number	:	850-712-3779
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 CLOVERDALE BLVD
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-1405
Country	:	US
Telephone Number	:	850-712-3779
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	BROOKE HARRISON
Credential	:
Telephone Number	:	850-712-3779

Provider Enumeration Date	:	09/10/2014
Last Update Date	:	09/10/2014

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Directions to “LIFESTYLE COUNSELING ” Practice Location

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