Provider Demographics
NPI:1285977520
Name:MANTRA COUNSELING, LLC
Entity type:Organization
Organization Name:MANTRA COUNSELING, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:LANIER
Authorized Official - Last Name:DATLA
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC,LMFT,CAP,DCC,NC
Authorized Official - Phone:352-262-2163
Mailing Address - Street 1:4230 SOUTH MACDILL AVE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-2912
Mailing Address - Country:US
Mailing Address - Phone:813-808-1956
Mailing Address - Fax:888-977-1272
Practice Address - Street 1:4230 SOUTH MACDILL AVE
Practice Address - Street 2:SUITE 209
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33611-2912
Practice Address - Country:US
Practice Address - Phone:813-808-1956
Practice Address - Fax:888-977-1272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-05
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 8831101YM0800X
FLMT 2809106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty