Healthcare Provider Details

I. General information

NPI: 1417494626
Provider Name (Legal Business Name): WAKIMG EXUME M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2017
Last Update Date: 01/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 FOREST HILL BLVD FL 2
WEST PALM BEACH FL
33406-5812
US

IV. Provider business mailing address

4180 BROOK CIR W
WEST PALM BEACH FL
33417-8203
US

V. Phone/Fax

Practice location:
  • Phone: 561-721-2887
  • Fax:
Mailing address:
  • Phone: 561-537-9645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number15087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: