Healthcare Provider Details

I. General information

NPI: 1154938280
Provider Name (Legal Business Name): SPARROW'S HAVEN SOLACE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2020
Last Update Date: 09/23/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 OAKFIELD DRIVE
BRANDON FL
33511-2800
US

IV. Provider business mailing address

1403 OAKFIELD DRIVE
BRANDON FL
33511-2800
US

V. Phone/Fax

Practice location:
  • Phone: 813-733-8586
  • Fax:
Mailing address:
  • Phone: 813-733-8586
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. MELANIE H. GRUNER
Title or Position: CLINICAL PASTORAL COUNSELOR
Credential: DMIN., MDIV.
Phone: 813-404-7214