Provider Demographics
NPI:1518406107
Name:MANTHERS PLACE COUNSELING
Entity Type:Organization
Organization Name:MANTHERS PLACE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:ELLETTA
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC, CST,MAC
Authorized Official - Phone:904-743-2327
Mailing Address - Street 1:6108 ARLINGTON RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211-5420
Mailing Address - Country:US
Mailing Address - Phone:904-743-2353
Mailing Address - Fax:
Practice Address - Street 1:6108 ARLINGTON RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-5420
Practice Address - Country:US
Practice Address - Phone:904-743-2353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANTHERS PLACE COUNSELING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH14118101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty