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General NPI Number Information
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NPI Number | 1205176609
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Entity Type | Organization
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Legal Business Name | SPIRITED AWAY ART THERAPY, LLC
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Dates
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Enumeration Date | 02/21/2013
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Last Update Date | 08/26/2019
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Provider Practice Location Address
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Address Line | 1505 TAMIAMI TRL S STE 402
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City | VENICE
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State | FL
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Zip | 34285-5563
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Country | US
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Telephone | 941-882-0590
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Fax |
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Provider Business Mailing Address
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Address Line | 1607 LARCHWOOD DR
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City | VENICE
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State | FL
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Zip | 34293-1016
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Country | US
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Telephone | 941-296-5759
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Fax |
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Authorized Official
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Title or Position | LMHC, ART THERAPIST
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Name | MRS. LISA RW RICHARDSON
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Credential | LMHC, LPC
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Telephone | 941-882-0590
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | MH11228
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 221700000X
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Taxonomy Name | Art Therapist
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License Number | MH11228
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State | CT
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Taxonomy #5
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH11228
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License Number State | FL
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