Healthcare Provider Details

I. General information

NPI: 1053786541
Provider Name (Legal Business Name): LAWRENCE DEVINE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/09/2015
Last Update Date: 12/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 N DIXIE HWY
POMPANO BEACH FL
33060-5621
US

IV. Provider business mailing address

3788 TURTLE RUN BLVD APT 2232
CORAL SPRINGS FL
33067
US

V. Phone/Fax

Practice location:
  • Phone: 954-785-8285
  • Fax: 954-928-0040
Mailing address:
  • Phone: 786-368-9159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH 6709
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: