Healthcare Provider Details

I. General information

NPI: 1578319042
Provider Name (Legal Business Name): SHATTERED NOT BROKEN THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2024
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 SW 34TH AVE STE 905-343
OCALA FL
34474-7447
US

IV. Provider business mailing address

3101 SW 34TH AVE STE 905-343
OCALA FL
34474-7447
US

V. Phone/Fax

Practice location:
  • Phone: 484-808-5908
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: CYNTHIA MENARD CLINTON
Title or Position: OWNER
Credential: LMHC
Phone: 484-250-4794