Provider Demographics
NPI:1205613445
Name:SACRED WINGS COUNSELING, LLC
Entity type:Organization
Organization Name:SACRED WINGS COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSKE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, RPT
Authorized Official - Phone:386-984-5366
Mailing Address - Street 1:184 SW STORY PL
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-1101
Mailing Address - Country:US
Mailing Address - Phone:386-984-5366
Mailing Address - Fax:
Practice Address - Street 1:826 SW MAIN BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5742
Practice Address - Country:US
Practice Address - Phone:386-984-5366
Practice Address - Fax:386-287-6525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty