Healthcare Provider Details

I. General information

NPI: 1295557650
Provider Name (Legal Business Name): ALEXANDRA CONDA GOLA RMHCI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10823 BOYETTE RD
RIVERVIEW FL
33569-8012
US

IV. Provider business mailing address

10823 BOYETTE RD
RIVERVIEW FL
33569-8012
US

V. Phone/Fax

Practice location:
  • Phone: 813-214-9911
  • Fax:
Mailing address:
  • Phone: 813-214-9911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH26826
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: