Healthcare Provider Details

I. General information

NPI: 1003155003
Provider Name (Legal Business Name): MARY ESCUDIE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2013
Last Update Date: 02/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 W SADIE ST
BRANDON FL
33510-4440
US

IV. Provider business mailing address

15310 AMBERLY DR SUITE 250 #42
TAMPA FL
33647-2199
US

V. Phone/Fax

Practice location:
  • Phone: 813-438-5949
  • Fax:
Mailing address:
  • Phone: 813-546-4027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11422
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: