Healthcare Provider Details

I. General information

NPI: 1912794314
Provider Name (Legal Business Name): FAITH AND TRANSFORMATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2025
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 WOODBINE RD
PACE FL
32571-8706
US

IV. Provider business mailing address

8264 HIGHWAY 89
MILTON FL
32570-9048
US

V. Phone/Fax

Practice location:
  • Phone: 850-979-4432
  • Fax: 850-366-1070
Mailing address:
  • Phone: 850-449-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: LARISSA HEMLEY
Title or Position: OWNER
Credential:
Phone: 850-449-9340