Healthcare Provider Details

I. General information

NPI: 1053057935
Provider Name (Legal Business Name): MR AND MS MENTORING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2022
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 RIDGEWOOD AVE
HOLLY HILL FL
32117-1798
US

IV. Provider business mailing address

19 STARLING DR
DAYTONA BEACH FL
32117-1886
US

V. Phone/Fax

Practice location:
  • Phone: 386-999-0333
  • Fax:
Mailing address:
  • Phone: 386-262-9852
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: DERRICK TARIQ COLLINS EL
Title or Position: OWNER
Credential: M.S.W
Phone: 386-262-9852