Provider Demographics
NPI:1003312513
Name:FULLNESS OF LIFE COUNSELING, LLC
Entity Type:Organization
Organization Name:FULLNESS OF LIFE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YESENIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RETA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:941-962-2425
Mailing Address - Street 1:1823 25TH AVE E
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34208-7746
Mailing Address - Country:US
Mailing Address - Phone:941-962-2425
Mailing Address - Fax:
Practice Address - Street 1:1103 9TH AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-7717
Practice Address - Country:US
Practice Address - Phone:941-800-1513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)