Healthcare Provider Details

I. General information

NPI: 1952779977
Provider Name (Legal Business Name): SOUTH FLORIDA INTEGRATIVE MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 09/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5915 PONCE DE LEON BLVD STE 26
CORAL GABLES FL
33146-2435
US

IV. Provider business mailing address

5915 PONCE DE LEON BLVD STE 26
CORAL GABLES FL
33146-2435
US

V. Phone/Fax

Practice location:
  • Phone: 786-664-7810
  • Fax: 305-340-2646
Mailing address:
  • Phone: 786-664-7810
  • Fax: 305-340-2646

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-13-14627
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY8545
License Number StateFL

VIII. Authorized Official

Name: HUGH HUMPHERY
Title or Position: PSYCHIATRIST
Credential: M.D.
Phone: 786-664-7810