=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275038416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INNER GROWTH COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2018
-----------------------------------------------------
Last Update Date | 08/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13574 VILLAGE PARK DR STE 240
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837-7695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-233-1866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13574 VILLAGE PARK DR STE 240
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32837-7695
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-233-1866
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | WANDA MALDONADO
-----------------------------------------------------
Credential | LMHC MH12067
-----------------------------------------------------
Telephone | 407-233-1866
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | MH12067
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------