MEDICARE: SACRED WINGS 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1205613445
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SACRED WINGS COUNSELING, LLC

Provider Business Mailing Address
First Line	:	184 SW STORY PL
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32024-1101
Country	:	US
Telephone Number	:	386-984-5366
Fax Number	:

Provider Business Practice Location Address
First Line	:	826 SW MAIN BLVD STE 102
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-5742
Country	:	US
Telephone Number	:	386-984-5366
Fax Number	:	386-287-6525

Authorized Official
Title or Position	:	MENTAL HEALTH THERAPIST
Name	:	AMANDA MANSKE
Credential	:	LCSW, RPT
Telephone Number	:	386-984-5366

Provider Enumeration Date	:	09/12/2023
Last Update Date	:	09/12/2023

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