=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831954387
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MASTERING MENTAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/14/2024
-----------------------------------------------------
Last Update Date | 02/14/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25054 LAMBRUSCO LOOP
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33559-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-400-3645
-----------------------------------------------------
Fax | 813-358-9146
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25054 LAMBRUSCO LOOP
-----------------------------------------------------
City | LUTZ
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33559-1806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-400-3645
-----------------------------------------------------
Fax | 813-358-9146
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DA'TWAN LAURICE MATHIS
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 813-420-7361
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------