Provider Demographics
NPI:1295245520
Name:ALIVE & WELL CORP
Entity type:Organization
Organization Name:ALIVE & WELL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETER
Authorized Official - Prefix:MS
Authorized Official - First Name:MELLISSA
Authorized Official - Middle Name:LATOYA
Authorized Official - Last Name:JAGRUP
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:813-748-2912
Mailing Address - Street 1:PO BOX 120682
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34712-0682
Mailing Address - Country:US
Mailing Address - Phone:813-748-2912
Mailing Address - Fax:
Practice Address - Street 1:10344 VISTA PINES LOOP
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-9172
Practice Address - Country:US
Practice Address - Phone:813-748-2912
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9648251S00000X, 261QM0801X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)