Healthcare Provider Details

I. General information

NPI: 1982205290
Provider Name (Legal Business Name): THRIVE BEHAVIORAL SCIENCES - SOUTH FLORIDA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2020
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BRICKELL KEY DR
MIAMI FL
33131-2662
US

IV. Provider business mailing address

5510 N HESPERIDES ST
TAMPA FL
33614-5414
US

V. Phone/Fax

Practice location:
  • Phone: 727-418-2567
  • Fax:
Mailing address:
  • Phone: 813-467-6111
  • Fax: 813-467-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JOLENE DE LA GARDELLE
Title or Position: VP OPERATIONS
Credential:
Phone: 813-725-4991