Healthcare Provider Details

I. General information

NPI: 1669639530
Provider Name (Legal Business Name): FAMILY GUIDANCE AND COUNSELING CENTER OF CENTRAL FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2008
Last Update Date: 10/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3256 W LAKE MARY BLVD SUITE 1100
LAKE MARY FL
32746
US

IV. Provider business mailing address

107 BRANDIWOOD CT
DEBARY FL
32713-2242
US

V. Phone/Fax

Practice location:
  • Phone: 407-416-5611
  • Fax: 386-788-3600
Mailing address:
  • Phone: 386-490-5745
  • Fax: 386-788-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSW2941
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSW2941
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW2941
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberSW2941
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberSW2941
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License NumberSW2941
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberSW2941
License Number StateFL
# 8
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW2941
License Number StateFL

VIII. Authorized Official

Name: MR. CARL CHRISTIAN HERTENSTEIN
Title or Position: SOLE MBR
Credential: LCSW
Phone: 386-490-5745