Healthcare Provider Details

I. General information

NPI: 1902207145
Provider Name (Legal Business Name): THE COMMUNITY MENTAL WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/08/2014
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 W DEL WEBB BLVD
SUN CITY CENTER FL
33573-5224
US

IV. Provider business mailing address

1210 W DEL WEBB BLVD
SUN CITY CENTER FL
33573-5224
US

V. Phone/Fax

Practice location:
  • Phone: 813-777-9777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW12131
License Number StateFL

VIII. Authorized Official

Name: MR. EDMOND DUBREUIL
Title or Position: OWNER
Credential:
Phone: 813-777-9777