Healthcare Provider Details

I. General information

NPI: 1114202728
Provider Name (Legal Business Name): MYSELF DISCOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2011
Last Update Date: 12/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 SE 12TH ST
FT LAUDERDALE FL
33316-1937
US

IV. Provider business mailing address

400 SE 12TH ST
FT LAUDERDALE FL
33316-1937
US

V. Phone/Fax

Practice location:
  • Phone: 954-524-2217
  • Fax:
Mailing address:
  • Phone: 954-524-2217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW10552
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW10552
License Number StateFL

VIII. Authorized Official

Name: DEBBY GOTTLIEB
Title or Position: PRESIDENT
Credential: LCSW
Phone: 954-328-5429