Healthcare Provider Details

I. General information

NPI: 1033658687
Provider Name (Legal Business Name): THALIA RYDZ LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5210 S UNIVERSITY DR STE 105
DAVIE FL
33328-5315
US

IV. Provider business mailing address

5210 S UNIVERSITY DR STE 105
DAVIE FL
33328-5315
US

V. Phone/Fax

Practice location:
  • Phone: 305-900-7203
  • Fax: 866-757-5778
Mailing address:
  • Phone: 305-900-7203
  • Fax: 866-757-5778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW13860
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: