Healthcare Provider Details

I. General information

NPI: 1386879732
Provider Name (Legal Business Name): MICHAEL WARREN MANCHESTER MA, NCC, LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 10/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3074 W LAKE MARY BLVD 140
LAKE MARY FL
32746-6749
US

IV. Provider business mailing address

1140 S OSCEOLA AVE
ORLANDO FL
32806-1350
US

V. Phone/Fax

Practice location:
  • Phone: 407-324-7979
  • Fax: 407-324-7901
Mailing address:
  • Phone: 407-324-7979
  • Fax: 407-324-7901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMH9898
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9898
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH9898
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: