Healthcare Provider Details

I. General information

NPI: 1932762754
Provider Name (Legal Business Name): FULFILLED LIFE COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 STONE ST STE 204
JONESBORO AR
72401-4568
US

IV. Provider business mailing address

4609 SUMMIT RIDGE DR
JONESBORO AR
72404-9101
US

V. Phone/Fax

Practice location:
  • Phone: 901-501-6091
  • Fax: 870-466-4982
Mailing address:
  • Phone: 870-718-6199
  • Fax: 870-466-4982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. LEONARDO PATRICK GLOVER
Title or Position: CEO
Credential: LPC
Phone: 870-718-6199