=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992117253
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MID KEYS COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2014
-----------------------------------------------------
Last Update Date | 05/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11400 OVERSEAS HWY SUITE 224
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-395-2430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11400 OVERSEAS HWY SUITE 224
-----------------------------------------------------
City | MARATHON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33050-3600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-395-2430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MR. NICHOLAS TOMAN
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 305-395-2430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH9786
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------