Healthcare Provider Details

I. General information

NPI: 1861843047
Provider Name (Legal Business Name): MILLENIUM CLINIC OF DADE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 NW 165TH ST STE 206
MIAMI FL
33169-6306
US

IV. Provider business mailing address

500 NW 165TH ST STE 206
MIAMI FL
33169-6306
US

V. Phone/Fax

Practice location:
  • Phone: 786-657-2272
  • Fax:
Mailing address:
  • Phone: 786-657-2272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: KIMBERLY LYNN ROBERTS
Title or Position: GROUP FACILITATOR
Credential: EDM
Phone: 718-785-6367