MEDICARE: PHYLLIS WESLEY M.S., LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH0004133	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	134646	OTHER	FL	COMPSYCH PROVIDER #
2	62-55531	OTHER	FL	UBH PROVIDER #
3	180098	OTHER	FL	MHN PROVIDER #
4	269950	OTHER	FL	HEALTHEASE PROVIDER #

General Provider Information

NPI Number	:	1043311657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHYLLIS WESLEY M.S., LMHC

Provider Business Mailing Address
First Line	:	305 N SAINT CLAIR ABRAMS AVE
Second Line	:
City	:	TAVARES
State	:	FL
Zip	:	32778-3064
Country	:	US
Telephone Number	:	352-742-0069
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 N SAINT CLAIR ABRAMS AVE
Second Line	:
City	:	TAVARES
State	:	FL
Zip	:	32778-3064
Country	:	US
Telephone Number	:	352-742-0069
Fax Number	:	352-742-0755

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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