Healthcare Provider Details

I. General information

NPI: 1780091884
Provider Name (Legal Business Name): PHOENIX MENTAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2014
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2440 SE FEDERAL HWY
STUART FL
34994-4531
US

IV. Provider business mailing address

2440 SE FEDERAL HWY
STUART FL
34994-4531
US

V. Phone/Fax

Practice location:
  • Phone: 561-229-8314
  • Fax:
Mailing address:
  • Phone: 561-229-8314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12356
License Number StateFL

VIII. Authorized Official

Name: LYNN E VARELA
Title or Position: OWNER
Credential: LMHC
Phone: 561-229-8314