=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629812151
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARSIBIL MOGENSEN MA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2024
-----------------------------------------------------
Last Update Date | 06/20/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 924 N MAGNOLIA AVE STE 250
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-501-6726
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4725 NEW BROAD ST APT 309
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32814-6429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-435-0905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | IMH26005
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------