Healthcare Provider Details

I. General information

NPI: 1174109516
Provider Name (Legal Business Name): MENTAL THERAPY REHABILITATION 2020 CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 03/23/2021
Certification Date: 03/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12485 SW 137TH AVE STE 202
MIAMI FL
33186-4217
US

IV. Provider business mailing address

12485 SW 137TH AVE STE 202
MIAMI FL
33186-4217
US

V. Phone/Fax

Practice location:
  • Phone: 786-815-0900
  • Fax:
Mailing address:
  • Phone: 786-815-0900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LIXANDRA P QUINTOSA
Title or Position: PRESIDENT
Credential:
Phone: 786-815-0900