Healthcare Provider Details

I. General information

NPI: 1619360641
Provider Name (Legal Business Name): LIFE WELL BEHAVIORAL HEALTH CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2015
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 NW 87TH AVE STE 7
DORAL FL
33172-1604
US

IV. Provider business mailing address

2801 NW 87TH AVE STE 7
DORAL FL
33172-1604
US

V. Phone/Fax

Practice location:
  • Phone: 786-717-6881
  • Fax: 786-717-6355
Mailing address:
  • Phone: 786-717-6881
  • Fax: 786-717-6355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LIANET GONZALEZ
Title or Position: PRESIDENT
Credential:
Phone: 786-759-8995