Healthcare Provider Details

I. General information

NPI: 1508648072
Provider Name (Legal Business Name): AZUL MINDSPACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2023
Last Update Date: 10/19/2023
Certification Date: 10/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10631 HABITAT TRL
BOKEELIA FL
33922-3122
US

IV. Provider business mailing address

10631 HABITAT TRL
BOKEELIA FL
33922-3122
US

V. Phone/Fax

Practice location:
  • Phone: 786-505-4022
  • Fax:
Mailing address:
  • Phone: 786-505-4022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHELLE RENEE WHITE
Title or Position: PSYCHOLOGIST / OWNER
Credential: MA
Phone: 786-505-4022