Healthcare Provider Details

I. General information

NPI: 1457868812
Provider Name (Legal Business Name): DLJ CLINICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2018
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 FAIRWAY DR STE 140V
DEERFIELD BEACH FL
33441-1812
US

IV. Provider business mailing address

10 FAIRWAY DR STE 140V
DEERFIELD BEACH FL
33441-1812
US

V. Phone/Fax

Practice location:
  • Phone: 561-921-7149
  • Fax: 561-530-2039
Mailing address:
  • Phone: 561-921-7149
  • Fax: 561-530-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberSW13061
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DANYELL JOHNSON
Title or Position: CEO
Credential: LCSW
Phone: 561-921-7149