Healthcare Provider Details

I. General information

NPI: 1053820258
Provider Name (Legal Business Name):
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/21/2022
Certification Date: 08/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11200 SW 8th st
MIAMI FL
33199
US

IV. Provider business mailing address

8262 NE 1st Ave Apt 4
Miami FL
33138
US

V. Phone/Fax

Practice location:
  • Phone: 3053480570
  • Fax:
Mailing address:
  • Phone: 7866060238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH19035
License Number StateFlorida
# 2
Primary Taxonomy
Taxonomy Code
Taxonomy101YM0800X
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: