Provider Demographics
NPI:1750920435
Name:ONLY LIVE, LLC
Entity type:Organization
Organization Name:ONLY LIVE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BERTOLINO
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:772-678-9040
Mailing Address - Street 1:974 SW WORCESTER LN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-2648
Mailing Address - Country:US
Mailing Address - Phone:772-678-9040
Mailing Address - Fax:772-673-0790
Practice Address - Street 1:145 NW CENTRAL PARK PLZ STE 107
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2482
Practice Address - Country:US
Practice Address - Phone:772-678-9040
Practice Address - Fax:772-673-0790
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-30
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty