Provider Demographics
NPI:1992294375
Name:COUNSELING & WELLNESS BOUTIQUE LLC
Entity type:Organization
Organization Name:COUNSELING & WELLNESS BOUTIQUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAINA
Authorized Official - Middle Name:
Authorized Official - Last Name:THORPE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:813-591-4868
Mailing Address - Street 1:11705 BOYETTE RD # 248
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-5533
Mailing Address - Country:US
Mailing Address - Phone:813-591-4868
Mailing Address - Fax:813-279-2551
Practice Address - Street 1:1503 S US HIGHWAY 301 STE E16
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33619-5126
Practice Address - Country:US
Practice Address - Phone:813-591-4868
Practice Address - Fax:813-279-2551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty