MEDICARE: CALLIE JENNIFER NETTLES 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	MH14218	FL

General Provider Information

NPI Number	:	1417421363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CALLIE JENNIFER NETTLES LMHC

Provider Business Mailing Address
First Line	:	1521 W COMANCHE AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-1203
Country	:	US
Telephone Number	:	813-644-9659
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 S HYDE PARK AVE STE 120
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33606-4117
Country	:	US
Telephone Number	:	813-644-9659
Fax Number	:

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

Provider Enumeration Date	:	01/14/2019
Last Update Date	:	10/07/2020

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