Healthcare Provider Details

I. General information

NPI: 1306583083
Provider Name (Legal Business Name): MY MENTAL HEALTH SOLUTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2022
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 INTERNATIONAL PARKWAY FIFTH FLOOR
LAKE MARY FL
32746-4762
US

IV. Provider business mailing address

3083 NEVERLAND DR
NEW SMYRNA FL
32168-2442
US

V. Phone/Fax

Practice location:
  • Phone: 786-393-0315
  • Fax:
Mailing address:
  • Phone: 786-393-0315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGELA MARIA HANSEN
Title or Position: CLINICAL ADMINISTRATOR/OWNER
Credential: LCSW
Phone: 786-393-0315