Healthcare Provider Details

I. General information

NPI: 1932598851
Provider Name (Legal Business Name): MIVIP BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2015
Last Update Date: 01/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3475 SHERIDAN ST 101
HOLLYWOOD FL
33021-3663
US

IV. Provider business mailing address

398 CAMINO GARDENS BLVD 102
BOCA RATON FL
33432-5827
US

V. Phone/Fax

Practice location:
  • Phone: 855-496-4847
  • Fax:
Mailing address:
  • Phone: 561-392-3341
  • Fax: 561-829-5482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ISAAC VERBUKH
Title or Position: PRESIDENT
Credential:
Phone: 561-392-3341