Healthcare Provider Details

I. General information

NPI: 1952607848
Provider Name (Legal Business Name): PHILIP K DVORAK II L.M.H.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2011
Last Update Date: 02/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4905 LANTANA RD
LAKE WORTH FL
33463-6915
US

IV. Provider business mailing address

3035 BOLLARD RD
WEST PALM BEACH FL
33411-6423
US

V. Phone/Fax

Practice location:
  • Phone: 561-253-6790
  • Fax:
Mailing address:
  • Phone: 561-313-0901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 10512
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: