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General NPI Number Information
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NPI Number | 1932762754
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Entity Type | Organization
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Legal Business Name | FULFILLED LIFE COUNSELING, LLC
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Dates
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Enumeration Date | 04/17/2019
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Last Update Date | 04/17/2019
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Provider Practice Location Address
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Address Line | 1218 STONE ST STE 204
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City | JONESBORO
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State | AR
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Zip | 72401-4568
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Country | US
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Telephone | 901-501-6091
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Fax | 870-466-4982
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Provider Business Mailing Address
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Address Line | 4609 SUMMIT RIDGE DR
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City | JONESBORO
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State | AR
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Zip | 72404-9101
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Country | US
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Telephone | 870-718-6199
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Fax | 870-466-4982
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Authorized Official
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Title or Position | CEO
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Name | MR. LEONARDO PATRICK GLOVER
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Credential | LPC
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Telephone | 870-718-6199
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number |
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License Number State |
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