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General NPI Number Information
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NPI Number | 1962974766
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Entity Type | Organization
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Legal Business Name | MARA'S LIGHTHOUSE COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 12/19/2018
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Last Update Date | 12/19/2018
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Provider Practice Location Address
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Address Line | 6015 MORROW ST E STE 109
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2125
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Country | US
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Telephone | 904-990-8105
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Fax | 904-562-3359
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Provider Business Mailing Address
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Address Line | 6015 MORROW ST E STE 109
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2125
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Country | US
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Telephone | 904-990-8105
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Fax | 904-562-3359
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Authorized Official
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Title or Position | CREDENTIALING SPECIALISTS
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Name | STEPHANIE INGENITO
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Credential |
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Telephone | 570-352-3063
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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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