Healthcare Provider Details

I. General information

NPI: 1538527619
Provider Name (Legal Business Name): TREE OF LIFE COUNSELING CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2016
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8163 S FLORIDA AVE
FLORAL CITY FL
34436-3101
US

IV. Provider business mailing address

PO BOX 121
FLORAL CITY FL
34436-0121
US

V. Phone/Fax

Practice location:
  • Phone: 352-400-9118
  • Fax:
Mailing address:
  • Phone: 352-400-9118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW10704
License Number StateFL

VIII. Authorized Official

Name: LAURIE P KEEFE-CECERE
Title or Position: MANAGER
Credential: LCSW
Phone: 352-400-9118