Provider Demographics
NPI:1578670501
Name:INNOVATIVE COUNSELING EXPERIENCE
Entity Type:Organization
Organization Name:INNOVATIVE COUNSELING EXPERIENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:FERNANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGO
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:352-666-6744
Mailing Address - Street 1:3448 PLAZA AVE
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608-3945
Mailing Address - Country:US
Mailing Address - Phone:352-684-7665
Mailing Address - Fax:352-684-7665
Practice Address - Street 1:11097 HEARTH RD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-3704
Practice Address - Country:US
Practice Address - Phone:352-684-7665
Practice Address - Fax:352-684-7665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty