MEDICARE: HER TABLE COLLECTIVE THERAPY & WELLNESS 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1689471013
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HER TABLE COLLECTIVE THERAPY & WELLNESS LLC

Provider Business Mailing Address
First Line	:	7314 MARY JO AVE
Second Line	:
City	:	SOUTHPORT
State	:	FL
Zip	:	32409-4162
Country	:	US
Telephone Number	:	850-565-9028
Fax Number	:

Provider Business Practice Location Address
First Line	:	7314 MARY JO AVE
Second Line	:
City	:	SOUTHPORT
State	:	FL
Zip	:	32409-4162
Country	:	US
Telephone Number	:	850-565-9028
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HOLLY CHANCEY
Credential	:
Telephone Number	:	850-565-9028

Provider Enumeration Date	:	02/25/2025
Last Update Date	:	02/25/2025

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