MEDICARE: METAMORPHOSIS PSYCHOTHERAPY & COUNSELING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	SW12475	FL

General Provider Information

NPI Number	:	1053858365
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	METAMORPHOSIS PSYCHOTHERAPY & COUNSELING

Provider Business Mailing Address
First Line	:	4008 LADY PALM CT
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-2383
Country	:	US
Telephone Number	:	813-777-7407
Fax Number	:

Provider Business Practice Location Address
First Line	:	4008 LADY PALM CT
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33624-2383
Country	:	US
Telephone Number	:	813-777-7407
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	JENNIFER BETANCUR
Credential	:	LCSW
Telephone Number	:	813-777-7407

Provider Enumeration Date	:	01/24/2017
Last Update Date	:	01/24/2017

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