MEDICARE: MANTHER'S PLACE 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	ADC-010509-2015	FL
2	101YM0800X	Mental Health Counselor	IMH11902	FL

General Provider Information

NPI Number	:	1235504978
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANTHER'S PLACE COUNSELING LLC

Provider Business Mailing Address
First Line	:	6108 ARLINGTON RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-5420
Country	:	US
Telephone Number	:	904-743-2327
Fax Number	:	904-743-2353

Provider Business Practice Location Address
First Line	:	6108 ARLINGTON RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32211-5420
Country	:	US
Telephone Number	:	904-743-2327
Fax Number	:	904-743-2353

Authorized Official
Title or Position	:	CEO, PSYCHOTHERAPIST
Name	:	MRS. CONNIE E CLARK
Credential	:	MA, CCTP,CST
Telephone Number	:	904-743-2327

Provider Enumeration Date	:	12/07/2015
Last Update Date	:	12/07/2015

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