Healthcare Provider Details

I. General information

NPI: 1003408352
Provider Name (Legal Business Name): LIFE FULLY LIVED, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 12/24/2023
Certification Date: 12/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BRANDYWINE BLVD
TALLEYVILLE DE
19803-1838
US

IV. Provider business mailing address

19 BRANDYWINE BLVD
TALLEYVILLE DE
19803-1838
US

V. Phone/Fax

Practice location:
  • Phone: 302-703-7779
  • Fax:
Mailing address:
  • Phone: 302-703-7779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MEGAN DOYLE
Title or Position: OWNER
Credential: LPCMH
Phone: 443-466-7038