Healthcare Provider Details

I. General information

NPI: 1629692611
Provider Name (Legal Business Name): MDTELEPSYCHOTHERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 09/08/2020
Certification Date: 09/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19500 TURNBERRY WAY PH F
AVENTURA FL
33180-2539
US

IV. Provider business mailing address

19500 TURNBERRY WAY PH F
AVENTURA FL
33180-2539
US

V. Phone/Fax

Practice location:
  • Phone: 954-961-1500
  • Fax: 561-450-5230
Mailing address:
  • Phone: 786-877-5800
  • Fax: 561-450-5230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. MONIQUE MARTIN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 561-727-6196