Healthcare Provider Details

I. General information

NPI: 1194205542
Provider Name (Legal Business Name): NEW LIFE 360 INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2018
Last Update Date: 10/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1047 E BRANDON BLVD
BRANDON FL
33511-5515
US

IV. Provider business mailing address

1047 E BRANDON BLVD
BRANDON FL
33511-5515
US

V. Phone/Fax

Practice location:
  • Phone: 813-548-1166
  • Fax:
Mailing address:
  • Phone: 813-548-1166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QV0200X
TaxonomyVA Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHERRY BRADLEY
Title or Position: CEO
Credential: LCSW, MCAP
Phone: 734-658-5055