Provider Demographics
NPI:1285987453
Name:MANGROVE WELLNESS CENTER,INC
Entity type:Organization
Organization Name:MANGROVE WELLNESS CENTER,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:REIDSEMA
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:941-822-5620
Mailing Address - Street 1:1515 TAMIAMI TRAIL S.
Mailing Address - Street 2:SUITE 2
Mailing Address - City:VENICE
Mailing Address - State:FL
Mailing Address - Zip Code:34285
Mailing Address - Country:US
Mailing Address - Phone:941-822-5620
Mailing Address - Fax:855-239-0365
Practice Address - Street 1:1515 TAMIAMI TRAIL S.
Practice Address - Street 2:SUITE 2
Practice Address - City:VENICE
Practice Address - State:FL
Practice Address - Zip Code:34285
Practice Address - Country:US
Practice Address - Phone:941-822-5620
Practice Address - Fax:855-239-0365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH12785101YM0800X, 101YP2500X
FLPY5867101YP2500X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty