Healthcare Provider Details

I. General information

NPI: 1750877312
Provider Name (Legal Business Name): MAKAHALA HEPBURN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2018
Last Update Date: 11/29/2021
Certification Date: 11/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 S CONGRESS AVE STE 340
BOYNTON BEACH FL
33426-6562
US

IV. Provider business mailing address

1165 NW 45TH TER
LAUDERHILL FL
33313-6625
US

V. Phone/Fax

Practice location:
  • Phone: 954-297-8961
  • Fax:
Mailing address:
  • Phone: 954-297-8961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15501
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: