Provider Demographics
NPI: | 1467984179 |
---|---|
Name: | MENDING WOUNDED SOULS, PLLC |
Entity Type: | Organization |
Organization Name: | MENDING WOUNDED SOULS, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MANAGER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ANN |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DEPOOLW |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | LCSW |
Authorized Official - Phone: | 727-466-8559 |
Mailing Address - Street 1: | 1001 STARKEY RD |
Mailing Address - Street 2: | #67 |
Mailing Address - City: | LARGO |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33771-5495 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 727-466-8559 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 7190 SEMINOLE BLVD |
Practice Address - Street 2: | |
Practice Address - City: | SEMINOLE |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33772-5935 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-466-8559 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2017-03-31 |
Last Update Date: | 2017-03-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
FL | SW11317 | 1041C0700X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Single Specialty |