Provider Demographics
NPI:1326104001
Name:LICHTENWALTER, MARY KATHLEEN (LMHC, CAP, CCS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:LICHTENWALTER
Suffix:
Gender:F
Credentials:LMHC, CAP, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 DUNLAWTON AVE
Mailing Address - Street 2:SUITE#3
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8985
Mailing Address - Country:US
Mailing Address - Phone:386-957-3905
Mailing Address - Fax:386-402-8992
Practice Address - Street 1:1730 DUNLAWTON AVE
Practice Address - Street 2:SUITE #3
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8985
Practice Address - Country:US
Practice Address - Phone:386-957-3905
Practice Address - Fax:386-402-8992
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH10712101YM0800X
IN39001980A101YM0800X
INLCAC 870056A101YA0400X
FLCAP 5276101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200196900AMedicaid