Healthcare Provider Details

I. General information

NPI: 1457983777
Provider Name (Legal Business Name): SHAKE IT UP FOUNDATION LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2020
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6919 W BROWARD BLVD STE 151
PLANTATION FL
33317-2902
US

IV. Provider business mailing address

6919 W BROWARD BLVD STE 151
PLANTATION FL
33317-2902
US

V. Phone/Fax

Practice location:
  • Phone: 954-283-0747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL FARNUM
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.S. LMHC
Phone: 570-540-3465