Healthcare Provider Details

I. General information

NPI: 1245782176
Provider Name (Legal Business Name): SOUTH FLORIDA NEURO WELLNESS CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5337 ORANGE DR
DAVIE FL
33314-3815
US

IV. Provider business mailing address

6191 ORANGE DR
DAVIE FL
33314-3449
US

V. Phone/Fax

Practice location:
  • Phone: 954-284-0025
  • Fax: 954-252-4037
Mailing address:
  • Phone: 954-284-0025
  • Fax: 954-252-4037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMT3051
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY6992
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY6992
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT2760
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateFL

VIII. Authorized Official

Name: MRS. SHELLY LAHN
Title or Position: OWNER
Credential: MBR
Phone: 954-284-0025