Provider Demographics
NPI:1538205885
Name:PALM HARBOR FAMILY COUNSELING CENTER INC.
Entity type:Organization
Organization Name:PALM HARBOR FAMILY COUNSELING CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MILLER MANDELL
Authorized Official - Suffix:
Authorized Official - Credentials:MSSA
Authorized Official - Phone:727-656-9665
Mailing Address - Street 1:700 VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-2935
Mailing Address - Country:US
Mailing Address - Phone:727-254-9183
Mailing Address - Fax:888-345-7010
Practice Address - Street 1:350 ALT 19
Practice Address - Street 2:C
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34683-5303
Practice Address - Country:US
Practice Address - Phone:727-254-9183
Practice Address - Fax:888-345-7010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI0005085101Y00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty