MEDICARE: A FULFILLED LIFE INTERNATIONAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1215590369
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A FULFILLED LIFE INTERNATIONAL

Provider Business Mailing Address
First Line	:	PO BOX 2622
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32961-2622
Country	:	US
Telephone Number	:	772-985-4941
Fax Number	:

Provider Business Practice Location Address
First Line	:	3150 CARDINAL DR
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32963-1931
Country	:	US
Telephone Number	:	772-985-4941
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	MR. FAMOUS ERWN
Credential	:	LMHC
Telephone Number	:	772-985-4941

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	04/15/2019

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