Basic Information
| Provider Information | |||||||||
| NPI: | 1760706485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JANE | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5707 N 22ND ST | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336104350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132722878 | ||||||||
| FaxNumber: | 8132723766 | ||||||||
| Practice Location | |||||||||
| Address1: | 4024 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT PETERSBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337111239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273277656 | ||||||||
| FaxNumber: | 7273222110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2010 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH1665 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.