Healthcare Provider Details

I. General information

NPI: 1043669922
Provider Name (Legal Business Name): ANDY ANSOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2016
Last Update Date: 06/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2411 NW 98TH AVE
SUNRISE FL
33322-3262
US

IV. Provider business mailing address

2411 NW 98TH AVE
SUNRISE FL
33322-3262
US

V. Phone/Fax

Practice location:
  • Phone: 954-274-7233
  • Fax: 877-795-9105
Mailing address:
  • Phone: 954-274-7233
  • Fax: 877-795-9105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: