MEDICARE: INTENTIONAL LIFE THERAPY

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1265180285
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTENTIONAL LIFE THERAPY

Provider Business Mailing Address
First Line	:	9895 HUFFMAN RD
Second Line	:
City	:	PORTAGE
State	:	OH
Zip	:	43451-9739
Country	:	US
Telephone Number	:	419-913-4255
Fax Number	:

Provider Business Practice Location Address
First Line	:	10951 E GYPSY LANE RD
Second Line	:
City	:	BOWLING GREEN
State	:	OH
Zip	:	43402-9565
Country	:	US
Telephone Number	:	419-913-4255
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	NICOLE FLORES-MCCUNE
Credential	:
Telephone Number	:	419-913-4255

Provider Enumeration Date	:	03/17/2022
Last Update Date	:	04/25/2022

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Directions to “INTENTIONAL LIFE THERAPY ” Practice Location

Language	Start Address	Practice Location

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