Healthcare Provider Details

I. General information

NPI: 1538205885
Provider Name (Legal Business Name): PALM HARBOR FAMILY COUNSELING CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 ALT 19 C
PALM HARBOR FL
34683-5303
US

IV. Provider business mailing address

700 VILLAGE WAY
PALM HARBOR FL
34683-2935
US

V. Phone/Fax

Practice location:
  • Phone: 727-254-9183
  • Fax: 888-345-7010
Mailing address:
  • Phone: 727-254-9183
  • Fax: 888-345-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberI0005085
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberI0005085
License Number StateOH

VIII. Authorized Official

Name: DIANE J MILLER MANDELL
Title or Position: OWNER THERAPIST
Credential: MSSA
Phone: 727-656-9665