Provider Demographics
NPI:1932762754
Name:FULFILLED LIFE COUNSELING, LLC
Entity Type:Organization
Organization Name:FULFILLED LIFE COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GLOVER
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:870-718-6199
Mailing Address - Street 1:4609 SUMMIT RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9101
Mailing Address - Country:US
Mailing Address - Phone:870-718-6199
Mailing Address - Fax:870-466-4982
Practice Address - Street 1:1218 STONE ST STE 204
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4568
Practice Address - Country:US
Practice Address - Phone:901-501-6091
Practice Address - Fax:870-466-4982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1093088031OtherQUALCHOICE
AR1093088031OtherBCBS