Healthcare Provider Details

I. General information

NPI: 1639708183
Provider Name (Legal Business Name): HEALING HEARTS TRAUMA THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2689 ANDROS LN
KISSIMMEE FL
34747-1808
US

IV. Provider business mailing address

10922 SCHUETZ RD
SAINT LOUIS MO
63146-5704
US

V. Phone/Fax

Practice location:
  • Phone: 772-773-0065
  • Fax: 949-655-5979
Mailing address:
  • Phone: 772-773-0065
  • Fax: 949-655-5979

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

VIII. Authorized Official

Name: SHARNITA WHITE
Title or Position: CEO
Credential:
Phone: 813-557-4701