Healthcare Provider Details

I. General information

NPI: 1285987453
Provider Name (Legal Business Name): MANGROVE WELLNESS CENTER,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 TAMIAMI TRAIL S. SUITE 2
VENICE FL
34285
US

IV. Provider business mailing address

1515 TAMIAMI TRAIL S. SUITE 2
VENICE FL
34285
US

V. Phone/Fax

Practice location:
  • Phone: 941-822-5620
  • Fax: 855-239-0365
Mailing address:
  • Phone: 941-822-5620
  • Fax: 855-239-0365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12785
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPY5867
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH12785
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY5867
License Number StateFL

VIII. Authorized Official

Name: LISA REIDSEMA
Title or Position: PRESIDENT
Credential: LMHC
Phone: 941-822-5620