Provider Demographics
NPI:1679030084
Name:INTEGRATED LIFE COUNSELING AND BEHAVIOR SERVICES
Entity Type:Organization
Organization Name:INTEGRATED LIFE COUNSELING AND BEHAVIOR SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANACAROLINA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:321-848-1916
Mailing Address - Street 1:1175 2ND PL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3029
Mailing Address - Country:US
Mailing Address - Phone:321-848-1916
Mailing Address - Fax:
Practice Address - Street 1:200 WAYMONT CT STE 126-10
Practice Address - Street 2:
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3413
Practice Address - Country:US
Practice Address - Phone:407-488-7927
Practice Address - Fax:407-603-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-22
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021251000Other39- MEDICAID