Provider Demographics
NPI:1003408352
Name:LIFE FULLY LIVED, LLC
Entity Type:Organization
Organization Name:LIFE FULLY LIVED, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:LPCMH
Authorized Official - Phone:443-466-7038
Mailing Address - Street 1:19 BRANDYWINE BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLEYVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19803-1838
Mailing Address - Country:US
Mailing Address - Phone:302-703-7779
Mailing Address - Fax:
Practice Address - Street 1:19 BRANDYWINE BLVD
Practice Address - Street 2:
Practice Address - City:TALLEYVILLE
Practice Address - State:DE
Practice Address - Zip Code:19803-1838
Practice Address - Country:US
Practice Address - Phone:302-703-7779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-08
Last Update Date:2023-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1366405433Medicaid
DE1124693056Medicaid
DE1538734959Medicaid
DE1275287823Medicaid
DE1023361136Medicaid
DE1134272610Medicaid
DE1891379467Medicaid
DE1093300527Medicaid
DE1134488711Medicaid