Healthcare Provider Details

I. General information

NPI: 1366790552
Provider Name (Legal Business Name): NOVA SOUTHEASTERN UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2012
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3526 S UNIVERSITY DR
DAVIE FL
33328-2002
US

IV. Provider business mailing address

PO BOX 290250
DAVIE FL
33329-0250
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-5730
  • Fax: 954-262-3855
Mailing address:
  • Phone: 954-262-4334
  • Fax: 954-262-3882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: ROBERT S. OLLER
Title or Position: CEO/DIVISION OF CLINICAL OPERATIONS
Credential: D.O.
Phone: 954-262-4399