Healthcare Provider Details

I. General information

NPI: 1811224454
Provider Name (Legal Business Name): KONDOOR VERGHESE ABRAHAM PSY.D., LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2009
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 SW 116 AVE.,
DAVIE FL
33325
US

IV. Provider business mailing address

1750 SW 116TH AVE
DAVIE FL
33325-4742
US

V. Phone/Fax

Practice location:
  • Phone: 954-916-1200
  • Fax:
Mailing address:
  • Phone: 954-916-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH1215
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: