Provider Demographics
NPI:1750453270
Name:CENTER OF LIFE HEALTH, INC.
Entity type:Organization
Organization Name:CENTER OF LIFE HEALTH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:772-220-4556
Mailing Address - Street 1:322 SW OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994
Mailing Address - Country:US
Mailing Address - Phone:772-220-4556
Mailing Address - Fax:772-220-2214
Practice Address - Street 1:322 SW OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:772-220-4556
Practice Address - Fax:772-220-2214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH3692101YP2500X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty