MEDICARE: GROUNDWORK COUNSELING LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1164842761
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROUNDWORK COUNSELING LLC

Provider Business Mailing Address
First Line	:	400 S ORLANDO AVE
Second Line	:	SUITE 206
City	:	MAITLAND
State	:	FL
Zip	:	32751-5644
Country	:	US
Telephone Number	:	407-378-3000
Fax Number	:

Provider Business Practice Location Address
First Line	:	400 S ORLANDO AVE
Second Line	:	SUITE 206
City	:	MAITLAND
State	:	FL
Zip	:	32751-5644
Country	:	US
Telephone Number	:	407-378-3000
Fax Number	:

Authorized Official
Title or Position	:	CO-OWNER
Name	:	COURTNEY RODRIGUE
Credential	:
Telephone Number	:	407-378-3000

Provider Enumeration Date	:	04/22/2014
Last Update Date	:	04/22/2014

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