Provider Demographics
NPI:1487614582
Name:KANTZLER, CHERYL MARIELLE (MS, LMHC)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:MARIELLE
Last Name:KANTZLER
Suffix:
Gender:F
Credentials:MS, LMHC
Other - Prefix:
Other - First Name:C. MARIELLE
Other - Middle Name:
Other - Last Name:KANTZLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:2100 CONSTITUTION BLVD STE 115
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34231-4146
Mailing Address - Country:US
Mailing Address - Phone:941-313-1878
Mailing Address - Fax:941-244-5231
Practice Address - Street 1:2100 CONSTITUTION BLVD # 115
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-4146
Practice Address - Country:US
Practice Address - Phone:941-404-3781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH9749222Q00000X
FLMH 9749101YM0800X
00073730225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104535500Medicaid