=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376246223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANGATA WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2023
-----------------------------------------------------
Last Update Date | 03/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 613 SW CAMDEN AVE
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-2924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-800-5591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 613 SW CAMDEN AVE
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994-2924
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-800-5591
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KIMBERLEE FRISOSKY
-----------------------------------------------------
Credential | LCSW, CAP
-----------------------------------------------------
Telephone | 269-275-3508
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------