Healthcare Provider Details

I. General information

NPI: 1831573740
Provider Name (Legal Business Name): LIFE SHAPE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2015
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2575 LONE PINE RD
WEST PALM BEACH FL
33410-2447
US

IV. Provider business mailing address

PO BOX 30004
PALM BEACH GARDENS FL
33420-0004
US

V. Phone/Fax

Practice location:
  • Phone: 561-379-4337
  • Fax:
Mailing address:
  • Phone:
  • 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 Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: CRAIG KERNS
Title or Position: OWNER/MANAGER
Credential:
Phone: 561-379-4337