Healthcare Provider Details

I. General information

NPI: 1225641616
Provider Name (Legal Business Name): THERAPEUTIC LIFE SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16071 MICELLI DR
WINTER GARDEN FL
34787-1821
US

IV. Provider business mailing address

7830 NW 161ST TER
MIAMI LAKES FL
33016-6677
US

V. Phone/Fax

Practice location:
  • Phone: 305-607-2896
  • 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 Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: DAVID GOMEZ
Title or Position: MR.
Credential: MS, LMHC, BCBA
Phone: 305-607-2896