MEDICARE: ONLY LIVE, LLC

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	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1750920435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONLY LIVE, LLC

Provider Business Mailing Address
First Line	:	974 SW WORCESTER LN
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-2648
Country	:	US
Telephone Number	:	772-678-9040
Fax Number	:	772-673-0790

Provider Business Practice Location Address
First Line	:	145 NW CENTRAL PARK PLZ STE 107
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34986-2482
Country	:	US
Telephone Number	:	772-678-9040
Fax Number	:	772-673-0790

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR, CEO
Name	:	MR. PAUL MATTHEW BERTOLINO
Credential	:	LCSW
Telephone Number	:	772-678-9040

Provider Enumeration Date	:	12/30/2019
Last Update Date	:	04/21/2023

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Directions to “ONLY LIVE, LLC ” Practice Location

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