MEDICARE: VENATORIA ELLEN ASBURY-STAPLE 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
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1417257460
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VENATORIA ELLEN ASBURY-STAPLE LMHC

Provider Business Mailing Address
First Line	:	907 COQUINA ST SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-4518
Country	:	US
Telephone Number	:	321-704-7493
Fax Number	:

Provider Business Practice Location Address
First Line	:	907 COQUINA ST SE
Second Line	:
City	:	PALM BAY
State	:	FL
Zip	:	32909-4518
Country	:	US
Telephone Number	:	321-704-7493
Fax Number	:

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

Provider Enumeration Date	:	10/25/2010
Last Update Date	:	10/25/2010

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