MEDICARE: PALM HARBOR FAMILY COUNSELING CENTER INC.

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	101Y00000X	Counselor	I0005085	OH
2	104100000X	Social Worker	I0005085	OH

General Provider Information

NPI Number	:	1538205885
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALM HARBOR FAMILY COUNSELING CENTER INC.

Provider Business Mailing Address
First Line	:	700 VILLAGE WAY
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-2935
Country	:	US
Telephone Number	:	727-254-9183
Fax Number	:	888-345-7010

Provider Business Practice Location Address
First Line	:	350 ALT 19
Second Line	:	C
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-5303
Country	:	US
Telephone Number	:	727-254-9183
Fax Number	:	888-345-7010

Authorized Official
Title or Position	:	OWNER THERAPIST
Name	:	DIANE J MILLER MANDELL
Credential	:	MSSA
Telephone Number	:	727-656-9665

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	11/04/2014

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