MEDICARE: PURPLE PASSION ENTERPRISES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QD1600X	Developmental Disabilities Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1790467611
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PURPLE PASSION ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	5045 E HINSON AVE
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-8872
Country	:	US
Telephone Number	:	863-557-3944
Fax Number	:

Provider Business Practice Location Address
First Line	:	5045 E HINSON AVE
Second Line	:
City	:	HAINES CITY
State	:	FL
Zip	:	33844-8872
Country	:	US
Telephone Number	:	863-557-3944
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. CHARLYN MOORE
Credential	:	LMHC, NCC
Telephone Number	:	863-557-3944

Provider Enumeration Date	:	08/01/2023
Last Update Date	:	08/01/2023

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