Healthcare Provider Details

I. General information

NPI: 1497355044
Provider Name (Legal Business Name): TRINITY THERAPEUTIC WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2020
Last Update Date: 09/23/2021
Certification Date: 11/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8400 N UNIVERSITY DR STE 114
TAMARAC FL
33321-1700
US

IV. Provider business mailing address

4960 NW 16TH ST
LAUDERHILL FL
33313-5526
US

V. Phone/Fax

Practice location:
  • Phone: 954-562-1955
  • Fax: 954-510-6935
Mailing address:
  • Phone: 305-308-2079
  • Fax: 954-510-6935

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: DR. MALCOLM L THOMAS JR.
Title or Position: CEO, CLINICIAN
Credential: LMHC, DMIN
Phone: 305-308-2079