Healthcare Provider Details

I. General information

NPI: 1265180285
Provider Name (Legal Business Name): INTENTIONAL LIFE THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10951 E GYPSY LANE RD
BOWLING GREEN OH
43402-9565
US

IV. Provider business mailing address

9895 HUFFMAN RD
PORTAGE OH
43451-9739
US

V. Phone/Fax

Practice location:
  • Phone: 419-913-4255
  • Fax:
Mailing address:
  • Phone: 419-913-4255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: NICOLE FLORES-MCCUNE
Title or Position: OWNER/PROVIDER
Credential:
Phone: 419-913-4255