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General NPI Number Information
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NPI Number | 1841070109
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Entity Type | Organization
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Legal Business Name | BLACK SWAN COUNSELING SERVICES, LLC
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Dates
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Enumeration Date | 10/04/2023
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Last Update Date | 01/30/2025
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Provider Practice Location Address
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Address Line | 100 S KENTUCKY AVE STE 240
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City | LAKELAND
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State | FL
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Zip | 33801-5093
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Country | US
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Telephone | 863-272-9137
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Fax |
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Provider Business Mailing Address
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Address Line | 100 S KENTUCKY AVE STE 240
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City | LAKELAND
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State | FL
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Zip | 33801-5093
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Country | US
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Telephone | 863-272-9137
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Fax |
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | KEVIN BERRY
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Credential | LMHC
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Telephone | 863-667-8570
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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