Healthcare Provider Details

I. General information

NPI: 1093472029
Provider Name (Legal Business Name): MUSTARD SEED COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13194 US HIGHWAY 301 S STE 210
RIVERVIEW FL
33578-7410
US

IV. Provider business mailing address

13194 US HIGHWAY 301 S STE 210
RIVERVIEW FL
33578-7410
US

V. Phone/Fax

Practice location:
  • Phone: 929-245-2704
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE JARA
Title or Position: OWNER
Credential: LCSW
Phone: 929-245-2704