Healthcare Provider Details

I. General information

NPI: 1982120325
Provider Name (Legal Business Name): MINDWEALTH INSTITUTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 SE 3RD AVE APT 435
DELRAY BEACH FL
33483-4683
US

IV. Provider business mailing address

151 SE 3RD AVE SUITE 435
DELRAY BEACH FL
33483
US

V. Phone/Fax

Practice location:
  • Phone: 202-297-0670
  • Fax:
Mailing address:
  • Phone: 202-297-0670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TR0400X
TaxonomyRehabilitation Psychologist
License NumberPY9528
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPY9528
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License NumberPY9528
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY9528
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY9528
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPY9528
License Number StateFL
# 7
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPY9528
License Number StateFL

VIII. Authorized Official

Name: DR. RICK STEPHAN
Title or Position: NEUROPSYCHOLOGIST
Credential: PH.D.
Phone: 202-297-0670