=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386199099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEANINGFUL SELF, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2016
-----------------------------------------------------
Last Update Date | 08/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6200 METROWEST BLVD STE 202
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32835-7638
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-286-2356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3104
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32802-3104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-286-2356
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. MARIBEL NIEVES
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 407-697-3207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171100000X
-----------------------------------------------------
Taxonomy Name | Acupuncturist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------