Healthcare Provider Details

I. General information

NPI: 1659822567
Provider Name (Legal Business Name): WELLNESS PROFESSIONAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2016
Last Update Date: 10/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SUNSET STRIP SUITE 4
SUNRISE FL
33313-6197
US

IV. Provider business mailing address

1100 SUNSET STRIP SUITE 4
SUNRISE FL
33313-6197
US

V. Phone/Fax

Practice location:
  • Phone: 954-446-3538
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JESICA RUSZ PAGLIONE DE ELIAS
Title or Position: OWNER
Credential:
Phone: 954-446-3538