Healthcare Provider Details

I. General information

NPI: 1962948323
Provider Name (Legal Business Name): MANNABA COUNSELING GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2017
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

498 PALM SPRINGS DR
ALTAMONTE SPRINGS FL
32701-7829
US

IV. Provider business mailing address

498 PALM SPRINGS DR 100-125
ALTAMONTE SPRINGS FL
32701-7829
US

V. Phone/Fax

Practice location:
  • Phone: 786-274-3549
  • Fax: 406-960-2634
Mailing address:
  • Phone: 786-274-3549
  • Fax: 406-274-3549

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH13032
License Number StateFL

VIII. Authorized Official

Name: MARIA TERESA PUENTES
Title or Position: PROGRAM DIRECTOR
Credential: LMHC; BCBA
Phone: 786-274-3549