Healthcare Provider Details

I. General information

NPI: 1518248418
Provider Name (Legal Business Name): BENJAMIN OUTREACH MEDICAL NETWORK CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 07/04/2025
Certification Date: 07/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 HOLLYWOOD BLVD STE 1B
HOLLYWOOD FL
33021-6749
US

IV. Provider business mailing address

3939 HOLLYWOOD BLVD STE 1B
HOLLYWOOD FL
33021-6749
US

V. Phone/Fax

Practice location:
  • Phone: 954-251-0267
  • Fax: 754-212-0473
Mailing address:
  • Phone: 954-251-0267
  • Fax: 954-239-7987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: ILNISE MATHIEU
Title or Position: OFFICE MANAGER
Credential:
Phone: 954-251-0267