Healthcare Provider Details

I. General information

NPI: 1528894094
Provider Name (Legal Business Name): A SPECTRUM OF SUCCESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SW 84TH AVE
PLANTATION FL
33324-2708
US

IV. Provider business mailing address

205 SW 84TH AVE
PLANTATION FL
33324-2708
US

V. Phone/Fax

Practice location:
  • Phone: 954-382-5570
  • Fax: 954-250-2529
Mailing address:
  • Phone: 954-382-5570
  • Fax: 954-250-2529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIDELKIS SERRA
Title or Position: PRESIDENT
Credential:
Phone: 954-382-5570