Healthcare Provider Details

I. General information

NPI: 1013059401
Provider Name (Legal Business Name): PROFESSIONAL TRAINING ASSOCIATION CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 02/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 NORTHLAKE BLVD #102
NORTH PALM BAECH FL
33408
US

IV. Provider business mailing address

321 NORTHLAKE BLVD SUITE 102
NORTH PALM BEACH FL
33408-5422
US

V. Phone/Fax

Practice location:
  • Phone: 561-494-0866
  • Fax: 561-494-0984
Mailing address:
  • Phone: 561-494-0866
  • Fax: 561-494-0984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number1550AD384701
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number0950AD384702
License Number StateFL

VIII. Authorized Official

Name: DR. MITCHELL E. WALLICK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 561-494-0866