=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528287877
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMARITAN COUNSELING CENTER OF TAMPA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2604 W AZEELE ST
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-872-7186
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2604 W AZEELE ST
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33609-4106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-872-7186
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DR. JOHN VINCENT MONSOUR
-----------------------------------------------------
Credential | D.MIN
-----------------------------------------------------
Telephone | 813-872-7186
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH 0001384
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------