MEDICARE: MANTHERS PLACE 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	MH14118	FL
2	101YM0800X	Mental Health Counselor	MH14118	FL

General Provider Information

NPI Number	:	1518406107
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MANTHERS PLACE COUNSELING

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

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

Authorized Official
Title or Position	:	THERAPIST
Name	:	CONNIE ELLETTA CLARK
Credential	:	MA, LMHC, CST,MAC
Telephone Number	:	904-743-2327

Provider Enumeration Date	:	02/16/2017
Last Update Date	:	02/16/2017

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