Healthcare Provider Details

I. General information

NPI: 1467487876
Provider Name (Legal Business Name): LIFE MANAGEMENT OF NW FL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 03/29/2024
Certification Date: 01/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 E 15TH ST
PANAMA CITY FL
32405-5412
US

IV. Provider business mailing address

525 E 15TH ST
PANAMA CITY FL
32405-5412
US

V. Phone/Fax

Practice location:
  • Phone: 850-522-4480
  • Fax: 850-914-6281
Mailing address:
  • Phone: 850-522-4480
  • Fax: 850-914-6281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: EDWIN AILES
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 850-522-4480