=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497235139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEVITATE LIFESTYLE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2018
-----------------------------------------------------
Last Update Date | 08/21/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 SHELBURNE RD STE 120
-----------------------------------------------------
City | SOUTH BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05403-7761
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-252-3437
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 64647
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05406-4647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMY CALDWELL
-----------------------------------------------------
Credential | LCMHC
-----------------------------------------------------
Telephone | 720-252-3437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 068.0134105
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------