Healthcare Provider Details

I. General information

NPI: 1285977520
Provider Name (Legal Business Name): MANTRA COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 10/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 SOUTH MACDILL AVE SUITE 209
TAMPA FL
33611-2912
US

IV. Provider business mailing address

4230 SOUTH MACDILL AVE SUITE 209
TAMPA FL
33611-2912
US

V. Phone/Fax

Practice location:
  • Phone: 813-808-1956
  • Fax: 888-977-1272
Mailing address:
  • Phone: 813-808-1956
  • Fax: 888-977-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 8831
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT 2809
License Number StateFL

VIII. Authorized Official

Name: AMY LANIER DATLA
Title or Position: OWNER
Credential: LMHC,LMFT,CAP,DCC,NC
Phone: 352-262-2163