Healthcare Provider Details

I. General information

NPI: 1700297181
Provider Name (Legal Business Name): METAMORPHOSIS COUNSELING AND WELLNESS SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

665 DILLARD DR SE VIRTUAL/ONLINE ONLY
PALM BAY FL
32909
US

IV. Provider business mailing address

PO BOX 100156
PALM BAY FL
32910-0156
US

V. Phone/Fax

Practice location:
  • Phone: 321-272-5996
  • Fax: 321-473-8874
Mailing address:
  • Phone: 321-272-5996
  • Fax: 321-473-8874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH15855
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number69138
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number7677
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA86130
License Number StateFL

VIII. Authorized Official

Name: ANNETTE MCDANIEL
Title or Position: CEO/COUNSELOR
Credential: NCC CCMHC LMHC
Phone: 321-272-5996