Healthcare Provider Details

I. General information

NPI: 1982227070
Provider Name (Legal Business Name): CLINICIANS OF SOUTH DADE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2020
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SE 2ND AVE STE 2000
MIAMI FL
33131-2185
US

IV. Provider business mailing address

525 N TRYON ST STE 1609
CHARLOTTE NC
28202-0202
US

V. Phone/Fax

Practice location:
  • Phone: 919-672-5005
  • Fax:
Mailing address:
  • Phone: 919-672-5005
  • 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: DASHUN TYRELL BANKS
Title or Position: CEO
Credential:
Phone: 919-672-5005