MEDICARE: INCLUSIVE THERAPY GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1811605710
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INCLUSIVE THERAPY GROUP

Provider Business Mailing Address
First Line	:	800 NW 29TH CT
Second Line	:
City	:	WILTON MANORS
State	:	FL
Zip	:	33311-2436
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 NW 29TH CT
Second Line	:
City	:	WILTON MANORS
State	:	FL
Zip	:	33311-2436
Country	:	US
Telephone Number	:	954-281-2565
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	CUB LARKIN
Credential	:
Telephone Number	:	954-281-2565

Provider Enumeration Date	:	11/09/2022
Last Update Date	:	11/09/2022

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