=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467984179
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENDING WOUNDED SOULS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2017
-----------------------------------------------------
Last Update Date | 03/31/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7190 SEMINOLE BLVD
-----------------------------------------------------
City | SEMINOLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33772-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-466-8559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 STARKEY RD #67
-----------------------------------------------------
City | LARGO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33771-5495
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-466-8559
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | ANN DEPOOLW
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 727-466-8559
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW11317
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------