Healthcare Provider Details

I. General information

NPI: 1568964344
Provider Name (Legal Business Name): MAKANDAL DAAGA MASTERS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 PONCE DE LEON BLVD FL 3
CORAL GABLES FL
33134-5039
US

IV. Provider business mailing address

2222 PONCE DE LEON BLVD FL 3
CORAL GABLES FL
33134-5039
US

V. Phone/Fax

Practice location:
  • Phone: 866-305-7365
  • Fax:
Mailing address:
  • Phone: 866-305-7365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: