Healthcare Provider Details

I. General information

NPI: 1215295068
Provider Name (Legal Business Name): IDALMIS NODAL LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 SW 8TH ST SUITE # 1
MIAMI FL
33174-2900
US

IV. Provider business mailing address

15630 SW 58TH ST
MIAMI FL
33193-2524
US

V. Phone/Fax

Practice location:
  • Phone: 305-559-8838
  • Fax: 305-559-6608
Mailing address:
  • Phone: 786-247-6496
  • Fax: 305-383-3296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH 9656
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: