Healthcare Provider Details

I. General information

NPI: 1417722620
Provider Name (Legal Business Name): FAMILY & ADOLESCENT BEHAVIORAL WELLNESS SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 11/17/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4365 NORTHLAKE BLVD
PALM BEACH GARDENS FL
33410-6253
US

IV. Provider business mailing address

PO BOX 31419
PALM BEACH GARDENS FL
33420-1419
US

V. Phone/Fax

Practice location:
  • Phone: 414-788-0014
  • Fax:
Mailing address:
  • Phone: 414-788-0014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW C RYAN
Title or Position: CHAIRMAN
Credential:
Phone: 414-788-0014