=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679019624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEART BONDS COUNSELING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2017
-----------------------------------------------------
Last Update Date | 08/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 EAST COLONIAL DRIVE SUITE 220
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803-4650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-801-3578
-----------------------------------------------------
Fax | 407-641-9081
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 600 EAST COLONIAL DRIVE SUITE 220
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32803-4650
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-801-3578
-----------------------------------------------------
Fax | 407-641-9081
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, LICENSED CLINICAL SOCIAL WOR
-----------------------------------------------------
Name | STACEY R GREENBERG
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 407-801-3578
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | SW 13127
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------