Provider Demographics
NPI:1356755060
Name:METAMORPHOSIS LIFE REVITALIZING CENTER
Entity type:Organization
Organization Name:METAMORPHOSIS LIFE REVITALIZING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:JACKSON-JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:813-703-2256
Mailing Address - Street 1:8430 MONTRAVAIL CIR
Mailing Address - Street 2:#313
Mailing Address - City:TEMPLE TERRACE
Mailing Address - State:FL
Mailing Address - Zip Code:33637-3024
Mailing Address - Country:US
Mailing Address - Phone:813-703-2256
Mailing Address - Fax:813-512-8904
Practice Address - Street 1:11700 N 58TH ST
Practice Address - Street 2:SUITE J
Practice Address - City:TEMPLE TERRACE
Practice Address - State:FL
Practice Address - Zip Code:33617-1666
Practice Address - Country:US
Practice Address - Phone:813-703-2256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-20
Last Update Date:2014-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8197103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty