1235504978 NPI number — MANTHER'S PLACE COUNSELING LLC

Table of content: (NPI 1235504978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235504978 NPI number — MANTHER'S PLACE COUNSELING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANTHER'S PLACE COUNSELING LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235504978
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6108 ARLINGTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32211-5420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-743-2327
Provider Business Mailing Address Fax Number:
904-743-2353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6108 ARLINGTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32211-5420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-743-2327
Provider Business Practice Location Address Fax Number:
904-743-2353
Provider Enumeration Date:
12/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CLARK
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
E
Authorized Official Title or Position:
CEO, PSYCHOTHERAPIST
Authorized Official Telephone Number:
904-743-2327

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  ADC-010509-2015 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YM0800X , with the licence number: IMH11902 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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