Healthcare Provider Details

I. General information

NPI: 1750453270
Provider Name (Legal Business Name): CENTER OF LIFE HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 10/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 SW OCEAN BLVD
STUART FL
34994
US

IV. Provider business mailing address

322 SW OCEAN BLVD
STUART FL
34994
US

V. Phone/Fax

Practice location:
  • Phone: 772-220-4556
  • Fax: 772-220-2214
Mailing address:
  • Phone: 772-220-4556
  • Fax: 772-220-2214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMH3692
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH3692
License Number StateFL

VIII. Authorized Official

Name: MS. KATHLEEN SUE FULLER
Title or Position: DIRECTOR
Credential: L.M.H.C.
Phone: 772-220-4556