=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881795755
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SARASOTA FAMILY YMCA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/25/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1084 S BRIGGS AVE
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34237-8133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-952-1644
-----------------------------------------------------
Fax | 941-953-5856
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1084 S BRIGGS AVE
-----------------------------------------------------
City | SARASOTA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34237-8133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-952-1644
-----------------------------------------------------
Fax | 941-953-5856
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MRS. SONIA T SANTIAGO
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 941-952-1644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 0004633
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------