Healthcare Provider Details

I. General information

NPI: 1912532441
Provider Name (Legal Business Name): 11911 PINE FOREST DRIVE, NEW PORT RITCHEY 34654
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11911 PINE FOREST DR
NEW PORT RICHEY FL
34654-1462
US

IV. Provider business mailing address

10144 ARBOR RUN DR UNIT 28
TAMPA FL
33647-3568
US

V. Phone/Fax

Practice location:
  • Phone: 813-526-4155
  • Fax:
Mailing address:
  • Phone: 813-526-4155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. NEVEH MAHILUM
Title or Position: OWNER/MANAGER
Credential:
Phone: 813-526-4155