Healthcare Provider Details

I. General information

NPI: 1013589902
Provider Name (Legal Business Name): FAMILY LIFE COUNSELING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2583 THORNHILL RD
AUBURNDALE FL
33823-4718
US

IV. Provider business mailing address

1230 OAKLEY SEAVER DR STE 307
CLERMONT FL
34711-1961
US

V. Phone/Fax

Practice location:
  • Phone: 352-988-6673
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: DAMARIS REVERON
Title or Position: OFFICE MANAGER
Credential:
Phone: 352-988-6673