Healthcare Provider Details

I. General information

NPI: 1205176609
Provider Name (Legal Business Name): SPIRITED AWAY ART THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 TAMIAMI TRL S STE 402
VENICE FL
34285-5563
US

IV. Provider business mailing address

1607 LARCHWOOD DR
VENICE FL
34293-1016
US

V. Phone/Fax

Practice location:
  • Phone: 941-882-0590
  • Fax:
Mailing address:
  • Phone: 941-296-5759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11228
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH11228
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License NumberMH11228
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateCT

VIII. Authorized Official

Name: MRS. LISA RW RICHARDSON
Title or Position: LMHC, ART THERAPIST
Credential: LMHC, LPC
Phone: 941-882-0590