=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649623448
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING FREE THERAPY SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2016
-----------------------------------------------------
Last Update Date | 12/08/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 MIRACLE STRIP PKWY SE
-----------------------------------------------------
City | FORT WALTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-611-3733
-----------------------------------------------------
Fax | 888-959-6012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 1004
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 833-611-3733
-----------------------------------------------------
Fax | 888-959-6013
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MRS. MELISSA NELSON
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 850-296-9047
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH13396
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------