1588307805 NPI number — SERENITY XCELLED COUNSELING LLC

Table of content: (NPI 1588307805)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588307805 NPI number — SERENITY XCELLED COUNSELING LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERENITY XCELLED 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:
1588307805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7037 SPOTTED DEER PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33578-8977
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-501-3124
Provider Business Mailing Address Fax Number:
813-492-2195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7901 4TH ST N STE 300
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ST PETERSBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33702-4399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-501-3124
Provider Business Practice Location Address Fax Number:
813-492-2195
Provider Enumeration Date:
04/14/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WATKINS
Authorized Official First Name:
DEMETRIC
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/FOUNDER
Authorized Official Telephone Number:
813-501-3124

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2024 www.npivalidator.com