Healthcare Provider Details

I. General information

NPI: 1346408721
Provider Name (Legal Business Name): SEAL THERAPEUTIC CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5818 SE AGNEW RD
BELLEVIEW FL
34420-4020
US

IV. Provider business mailing address

2735 SE 140TH PL
SUMMERFIELD FL
34491-2877
US

V. Phone/Fax

Practice location:
  • Phone: 561-715-5910
  • Fax: 561-892-0268
Mailing address:
  • Phone: 561-715-5910
  • Fax: 561-892-0268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSW8553
License Number StateFL

VIII. Authorized Official

Name: DR. NICOLE WOLLER
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 561-715-5910