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General NPI Number Information
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NPI Number | 1356755060
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Entity Type | Organization
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Legal Business Name | METAMORPHOSIS LIFE REVITALIZING CENTER
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Dates
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Enumeration Date | 06/20/2014
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Last Update Date | 06/20/2014
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Provider Practice Location Address
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Address Line | 11700 N 58TH ST SUITE J
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City | TEMPLE TERRACE
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State | FL
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Zip | 33617-1666
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Country | US
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Telephone | 813-703-2256
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Fax |
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Provider Business Mailing Address
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Address Line | 8430 MONTRAVAIL CIR #313
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City | TEMPLE TERRACE
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State | FL
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Zip | 33637-3024
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Country | US
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Telephone | 813-703-2256
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Fax | 813-512-8904
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | DR. APRIL MICHELLE JACKSON-JAMES
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Credential | PHD
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Telephone | 813-703-2256
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY8197
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License Number State | FL
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