Healthcare Provider Details

I. General information

NPI: 1619465309
Provider Name (Legal Business Name): FRUITFUL LIFE COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2018
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 STRADA AMORE APT 4
FLORENCE SC
29501-0245
US

IV. Provider business mailing address

1234 STRADA AMORE APT 4
FLORENCE SC
29501-0245
US

V. Phone/Fax

Practice location:
  • Phone: 770-778-3516
  • Fax:
Mailing address:
  • Phone: 770-778-3516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6099
License Number StateSC

VIII. Authorized Official

Name: MISS CARRIE LUSK
Title or Position: OWNER
Credential: LPC
Phone: 770-778-3516