Provider Demographics
NPI:1265180285
Name:INTENTIONAL LIFE THERAPY
Entity type:Organization
Organization Name:INTENTIONAL LIFE THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES-MCCUNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-913-4255
Mailing Address - Street 1:9895 HUFFMAN RD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:OH
Mailing Address - Zip Code:43451-9739
Mailing Address - Country:US
Mailing Address - Phone:419-913-4255
Mailing Address - Fax:
Practice Address - Street 1:10951 E GYPSY LANE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-9565
Practice Address - Country:US
Practice Address - Phone:419-913-4255
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-17
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty