Healthcare Provider Details

I. General information

NPI: 1316456387
Provider Name (Legal Business Name): MISTY BROOKE RUMMAGE LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/14/2022
Certification Date: 09/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 NW PEACOCK BLVD STE 10
PORT ST LUCIE FL
34986-2213
US

IV. Provider business mailing address

4740 N STATE ROAD 7
LAUDERDALE LAKES FL
33319-5839
US

V. Phone/Fax

Practice location:
  • Phone: 772-361-6767
  • Fax:
Mailing address:
  • Phone: 954-486-4005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberMH15388
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH15388
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: