Healthcare Provider Details

I. General information

NPI: 1396169819
Provider Name (Legal Business Name): SUPPORTIVE THERAPY EMPOWERING PEOPLE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W BRANDON BLVD SUITE 203
BRANDON FL
33511-5104
US

IV. Provider business mailing address

220 W BRANDON BLVD SUITE 203
BRANDON FL
33511-5104
US

V. Phone/Fax

Practice location:
  • Phone: 813-892-6203
  • Fax: 813-381-3909
Mailing address:
  • Phone: 813-892-6203
  • Fax: 813-381-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9398
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8425
License Number StateFL

VIII. Authorized Official

Name: REGINALD VILMENAY
Title or Position: LCSW
Credential: LCSW
Phone: 813-892-6203