=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992343172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE CENTER FOR COMPASSIONATE CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2019
-----------------------------------------------------
Last Update Date | 12/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6707 PLANTATION RD STE B3
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32504-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-207-7085
-----------------------------------------------------
Fax | 850-465-3255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6707 PLANTATION RD STE B3
-----------------------------------------------------
City | PENSACOLA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32504-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-207-7085
-----------------------------------------------------
Fax | 850-465-3255
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST/OWNER
-----------------------------------------------------
Name | MICKETTRIC MANN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 850-255-4131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------