Healthcare Provider Details

I. General information

NPI: 1356002364
Provider Name (Legal Business Name): MARY ANN KONSTAS ED.S., LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 01/03/2022
Certification Date: 01/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W KENNEDY BLVD STE 120
TAMPA FL
33609-2243
US

IV. Provider business mailing address

4100 W KENNEDY BLVD STE 120
TAMPA FL
33609-2243
US

V. Phone/Fax

Practice location:
  • Phone: 813-645-8284
  • Fax:
Mailing address:
  • Phone: 813-645-8284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH19897
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH19897
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMH19897
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberMH19897
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: