=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538879804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANIFEST MENTAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2022
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12485 SW 137TH AVE STE 212
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-505-6292
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12485 SW 137TH AVE STE 212
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33186-4217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-998-8060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MELISSA ORTEGA
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 305-998-8060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------