Healthcare Provider Details

I. General information

NPI: 1629368618
Provider Name (Legal Business Name): MARTHA MINTEER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2011
Last Update Date: 04/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 NW 83RD ST
GAINESVILLE FL
32606-6227
US

IV. Provider business mailing address

3303 NW 83RD ST
GAINESVILLE FL
32606-6227
US

V. Phone/Fax

Practice location:
  • Phone: 352-334-4060
  • Fax: 352-334-4059
Mailing address:
  • Phone: 352-334-4060
  • Fax: 352-334-4059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW9247
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: