Healthcare Provider Details

I. General information

NPI: 1871134627
Provider Name (Legal Business Name): MANDALA COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/28/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6361 PRESIDENTIAL CT STE 101
FORT MYERS FL
33919-3583
US

IV. Provider business mailing address

6361 PRESIDENTIAL CT STE 101
FORT MYERS FL
33919-3583
US

V. Phone/Fax

Practice location:
  • Phone: 239-360-1976
  • Fax:
Mailing address:
  • Phone: 239-360-1983
  • Fax:

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 Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIANNA KELLY JAWORSKI
Title or Position: OWNER
Credential: LMHC
Phone: 941-962-9661