Provider Demographics
NPI:1255734935
Name:PALM HARBOR FAMILY COUNSELING CENTER
Entity type:Organization
Organization Name:PALM HARBOR FAMILY COUNSELING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANDELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, MSSA
Authorized Official - Phone:727-254-9183
Mailing Address - Street 1:350 ALTERNATE 19
Mailing Address - Street 2:SUITE C
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683
Mailing Address - Country:US
Mailing Address - Phone:727-254-9183
Mailing Address - Fax:
Practice Address - Street 1:700 VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-2935
Practice Address - Country:US
Practice Address - Phone:727-254-9183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW11944261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health