Healthcare Provider Details

I. General information

NPI: 1083342109
Provider Name (Legal Business Name): NOVA SOUTHEASTERN UNIVERSITY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/27/2025
Certification Date: 08/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 COLLEGE AVENUE MAXWELL MALTZ BUILDING 1ST FLOOR
DAVIE FL
33314
US

IV. Provider business mailing address

PO BOX 290370
DAVIE FL
33329-0370
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-3030
  • Fax:
Mailing address:
  • Phone: 954-262-4343
  • Fax:

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 Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: LAKEITHA BAKER
Title or Position: CREDENTIALING SUPERVISOR
Credential:
Phone: 954-262-9416