Healthcare Provider Details

I. General information

NPI: 1922835669
Provider Name (Legal Business Name): PEDIATRIC INSTITUTE FOR HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2024
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 SE MONTEREY COMMONS BLVD STE 203
STUART FL
34996-3357
US

IV. Provider business mailing address

1002 SE MONTEREY COMMONS BLVD STE 203
STUART FL
34996-3357
US

V. Phone/Fax

Practice location:
  • Phone: 844-550-7337
  • Fax: 772-264-9820
Mailing address:
  • Phone: 844-550-7337
  • Fax: 772-264-9820

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE CLARK
Title or Position: CEO
Credential:
Phone: 844-550-7337