Healthcare Provider Details

I. General information

NPI: 1134502578
Provider Name (Legal Business Name): TATAYANA MALTSEVA APRN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1957 JACKSON ST
HOLLYWOOD FL
33020-5021
US

IV. Provider business mailing address

4740 N STATE ROAD 7
LAUDERDALE LAKES FL
33319-5839
US

V. Phone/Fax

Practice location:
  • Phone: 954-921-2600
  • Fax:
Mailing address:
  • Phone: 954-486-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPRN3027352
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN3027352
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: