Provider Demographics
NPI:1962948323
Name:MANNABA COUNSELING GROUP
Entity type:Organization
Organization Name:MANNABA COUNSELING GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:T
Authorized Official - Last Name:PUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LMHC,CST
Authorized Official - Phone:786-274-3549
Mailing Address - Street 1:4302 HOLLYWOOD BOULEVARD
Mailing Address - Street 2:#177
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021
Mailing Address - Country:US
Mailing Address - Phone:786-274-3549
Mailing Address - Fax:
Practice Address - Street 1:4302 HOLLYWOOD BLVD
Practice Address - Street 2:#177
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6635
Practice Address - Country:US
Practice Address - Phone:786-274-3549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-10
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13032101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty