Healthcare Provider Details

I. General information

NPI: 1295245520
Provider Name (Legal Business Name): ALIVE & WELL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10344 VISTA PINES LOOP
CLERMONT FL
34711-9172
US

IV. Provider business mailing address

PO BOX 120682
CLERMONT FL
34712-0682
US

V. Phone/Fax

Practice location:
  • Phone: 813-748-2912
  • Fax:
Mailing address:
  • Phone: 813-748-2912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9648
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMH9648
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberMH9648
License Number StateFL

VIII. Authorized Official

Name: MS. MELLISSA LATOYA JAGRUP
Title or Position: PROPRIETER
Credential: LMHC
Phone: 813-748-2912