MEDICARE: MANTRA COUNSELING, LLC

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	106H00000X	Marriage & Family Therapist	MT 2809	FL
2	101YM0800X	Mental Health Counselor	MH 8831	FL

General Provider Information

NPI Number	:	1285977520
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANTRA COUNSELING, LLC

Provider Business Mailing Address
First Line	:	4230 SOUTH MACDILL AVE
Second Line	:	SUITE 209
City	:	TAMPA
State	:	FL
Zip	:	33611-2912
Country	:	US
Telephone Number	:	813-808-1956
Fax Number	:	888-977-1272

Provider Business Practice Location Address
First Line	:	4230 SOUTH MACDILL AVE
Second Line	:	SUITE 209
City	:	TAMPA
State	:	FL
Zip	:	33611-2912
Country	:	US
Telephone Number	:	813-808-1956
Fax Number	:	888-977-1272

Authorized Official
Title or Position	:	OWNER
Name	:	AMY LANIER DATLA
Credential	:	LMHC,LMFT,CAP,DCC,NC
Telephone Number	:	352-262-2163

Provider Enumeration Date	:	04/05/2013
Last Update Date	:	10/31/2016

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