MEDICARE: PEACE AND MENTAL CROSSING

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1700584570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACE AND MENTAL CROSSING

Provider Business Mailing Address
First Line	:	6421 N FLORIDA AVE # D-382
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33604-6007
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3319 RUSSETT DR
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33618-1307
Country	:	US
Telephone Number	:	813-509-1315
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VANIECE JOHNSON
Credential	:	LCSW
Telephone Number	:	813-509-1315

Provider Enumeration Date	:	02/21/2023
Last Update Date	:	02/21/2023

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Directions to “PEACE AND MENTAL CROSSING ” Practice Location

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