Healthcare Provider Details

I. General information

NPI: 1942642632
Provider Name (Legal Business Name): WHITE PICKET FENCE COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2013
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1345 CLAY ST
WINTER PARK FL
32789-5404
US

IV. Provider business mailing address

1345 CLAY ST
WINTER PARK FL
32789-5404
US

V. Phone/Fax

Practice location:
  • Phone: 407-622-0202
  • Fax: 407-645-1017
Mailing address:
  • Phone: 407-622-0202
  • Fax: 407-645-1017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMH9281
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMH9281
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9281
License Number StateFL

VIII. Authorized Official

Name: MS. SANDEE NEBEL
Title or Position: PRESIDENT
Credential: LMHC
Phone: 407-622-0202