Provider Demographics
NPI:1396225918
Name:D. FENNELL JR, LLC
Entity Type:Organization
Organization Name:D. FENNELL JR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:FENNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-557-7118
Mailing Address - Street 1:8315 BERKELEY MANOR BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 N ASHLEY DR STE 2600
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33602-4310
Practice Address - Country:US
Practice Address - Phone:813-557-7118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-14
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH15956101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty