Provider Demographics
NPI:1750018305
Name:FULLY ALIVE THERAPIES LLC
Entity type:Organization
Organization Name:FULLY ALIVE THERAPIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JITHIN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:630-216-9881
Mailing Address - Street 1:5128 ARBOR GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-8043
Mailing Address - Country:US
Mailing Address - Phone:630-216-9881
Mailing Address - Fax:
Practice Address - Street 1:5128 ARBOR GLEN CIR
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33463-8043
Practice Address - Country:US
Practice Address - Phone:630-216-9881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-03
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty