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General NPI Number Information
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NPI Number | 1205613445
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Entity Type | Organization
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Legal Business Name | SACRED WINGS COUNSELING, LLC
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Dates
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Enumeration Date | 09/12/2023
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Last Update Date | 09/12/2023
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Provider Practice Location Address
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Address Line | 826 SW MAIN BLVD STE 102
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City | LAKE CITY
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State | FL
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Zip | 32025-5742
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Country | US
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Telephone | 386-984-5366
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Fax | 386-287-6525
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Provider Business Mailing Address
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Address Line | 184 SW STORY PL
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City | LAKE CITY
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State | FL
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Zip | 32024-1101
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Country | US
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Telephone | 386-984-5366
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Fax |
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Authorized Official
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Title or Position | MENTAL HEALTH THERAPIST
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Name | AMANDA MANSKE
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Credential | LCSW, RPT
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Telephone | 386-984-5366
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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