Healthcare Provider Details

I. General information

NPI: 1891346805
Provider Name (Legal Business Name): G3 LIFE APPLICATIONS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6403 N 45TH ST
TAMPA FL
33610-3980
US

IV. Provider business mailing address

2000 E 12TH AVE UNIT 5327
TAMPA FL
33675-9015
US

V. Phone/Fax

Practice location:
  • Phone: 813-956-6817
  • Fax:
Mailing address:
  • Phone: 813-956-6817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MR. RONNIE MCCULLOUGH
Title or Position: PRESIDENT
Credential:
Phone: 813-956-6817