1245513274 NPI number — PERSONAL ENRICHMENT THROUGH MENTAL HEALTH SERVICES

Table of content: (NPI 1245513274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245513274 NPI number — PERSONAL ENRICHMENT THROUGH MENTAL HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PERSONAL ENRICHMENT THROUGH MENTAL HEALTH SERVICES
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:
6
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:
1245513274
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11254 58TH ST N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINELLAS PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33782-2213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-545-6477
Provider Business Mailing Address Fax Number:
727-545-6464

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1614 PALM WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LARGO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33771-3926
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-545-6477
Provider Business Practice Location Address Fax Number:
727-507-4722
Provider Enumeration Date:
09/26/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WENNLUND
Authorized Official First Name:
GERALD
Authorized Official Middle Name:
F
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
727-545-6477

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , 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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