Healthcare Provider Details

I. General information

NPI: 1962715995
Provider Name (Legal Business Name): LORENA DISMUTE MA-COUNSELOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2010
Last Update Date: 10/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8870 N HIMES AVE # 150
TAMPA FL
33614-1627
US

IV. Provider business mailing address

8870 N HIMES AVE # 150
TAMPA FL
33614-1627
US

V. Phone/Fax

Practice location:
  • Phone: 813-735-5668
  • Fax:
Mailing address:
  • Phone: 813-735-5668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: