Healthcare Provider Details

I. General information

NPI: 1982170700
Provider Name (Legal Business Name): MENTAL AUTONOMY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 01/29/2026
Certification Date: 01/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 S UNIVERSITY DR STE 201C
DAVIE FL
33328-5308
US

IV. Provider business mailing address

5220 S UNIVERSITY DR STE 201C
DAVIE FL
33328-5308
US

V. Phone/Fax

Practice location:
  • Phone: 954-906-5947
  • Fax: 786-329-6876
Mailing address:
  • Phone: 954-906-5947
  • Fax: 786-329-6876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: LUIS RAFAEL PEROZO
Title or Position: OFFICER
Credential:
Phone: 954-906-5947