Healthcare Provider Details

I. General information

NPI: 1407111503
Provider Name (Legal Business Name): THE LIFE CENTER OF THE SUNCOAST, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2012
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6811 N. CENTRAL AVENUE
TAMPA FL
33604-5500
US

IV. Provider business mailing address

6811 N. CENTRAL AVENUE
TAMPA FL
33604-5500
US

V. Phone/Fax

Practice location:
  • Phone: 813-237-3114
  • Fax: 866-457-5422
Mailing address:
  • Phone: 813-237-3114
  • Fax: 866-457-5422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLMHC1340
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLMHC1340
License Number StateFL

VIII. Authorized Official

Name: MRS. SHERYLE R. BAKER
Title or Position: EXECUTIVE DIRECTOR & LICENSED COUNS
Credential: LMHC 1340
Phone: 813-237-3114