Provider Demographics
NPI:1013589902
Name:FAMILY LIFE COUNSELING CENTER LLC
Entity Type:Organization
Organization Name:FAMILY LIFE COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAMARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:REVERON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-988-6673
Mailing Address - Street 1:1230 OAKLEY SEAVER DR STE 307
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-1961
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2583 THORNHILL RD
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-4718
Practice Address - Country:US
Practice Address - Phone:352-988-6673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty