Healthcare Provider Details

I. General information

NPI: 1629831565
Provider Name (Legal Business Name): FORTUIDE WELLBEING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2024
Last Update Date: 04/15/2024
Certification Date: 04/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3425 BAYSIDE LAKES BLVD SE STE 103-1184
PALM BAY FL
32909-6867
US

IV. Provider business mailing address

3425 BAYSIDE LAKES BLVD SE STE 103-1184
PALM BAY FL
32909-6867
US

V. Phone/Fax

Practice location:
  • Phone: 321-325-6935
  • Fax: 321-325-6840
Mailing address:
  • Phone: 321-325-6935
  • Fax: 321-325-6840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN HIX
Title or Position: OWNER/MENTAL HEALTH COUNSELOR
Credential: LMHC
Phone: 321-325-6935