Healthcare Provider Details

I. General information

NPI: 1467007179
Provider Name (Legal Business Name): MENTAL HEALTH TRANSFORMATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 08/09/2020
Certification Date: 08/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 N 2ND ST
FLAGLER BEACH FL
32136-3343
US

IV. Provider business mailing address

324 N 2ND ST
FLAGLER BEACH FL
32136-3343
US

V. Phone/Fax

Practice location:
  • Phone: 386-530-5158
  • Fax: 386-693-4081
Mailing address:
  • Phone: 386-530-5158
  • Fax: 386-693-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MRS. KORIN A MENARD
Title or Position: OWNER
Credential: LMHC, RBT, MA
Phone: 386-530-5158