=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316256662
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HAFTEL HEALING ARTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2010
-----------------------------------------------------
Last Update Date | 10/05/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1885 S 14TH ST #5
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-3033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-206-0641
-----------------------------------------------------
Fax | 904-491-3337
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 97052 KATFISH LN
-----------------------------------------------------
City | YULEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32097-2477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-261-8744
-----------------------------------------------------
Fax | 904-491-3337
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. MARION E HAFTEL
-----------------------------------------------------
Credential | M. ED, LMHC
-----------------------------------------------------
Telephone | 904-206-0641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH5151
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------