Healthcare Provider Details

I. General information

NPI: 1427832328
Provider Name (Legal Business Name): ISAAC STAVOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1527 NE 4TH AVE
FORT LAUDERDALE FL
33304-1035
US

IV. Provider business mailing address

3520 NE 5TH ST APT 203
HOMESTEAD FL
33033-7668
US

V. Phone/Fax

Practice location:
  • Phone: 954-835-5741
  • Fax:
Mailing address:
  • Phone: 352-553-3767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: