Healthcare Provider Details

I. General information

NPI: 1750871810
Provider Name (Legal Business Name): ELLIOTT JASON ECKMANN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7481 W. OAKLAND PARK BLVD, SUITE 100
LAUDERHILL FL
33319-4985
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 888-852-6672
  • Fax: 786-235-6225
Mailing address:
  • Phone: 954-486-4005
  • Fax: 954-497-3857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW15145
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW15145
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: