=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225750110
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENTAL WELLNESS THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2022
-----------------------------------------------------
Last Update Date | 09/16/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6497 PARKLAND DR
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34243-4097
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-212-2040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11806 ACORN WOODS TER
-----------------------------------------------------
City | LAKEWOOD RANCH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202-2801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-212-2040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER
-----------------------------------------------------
Name | SHPRESA KALETSCH
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 941-212-2040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------