Healthcare Provider Details

I. General information

NPI: 1346967122
Provider Name (Legal Business Name): MARCHANT HALSOR LLC ELLIE MENTAL HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2853 EXECUTIVE PARK DR
WESTON FL
33331-3656
US

IV. Provider business mailing address

1703 NE 5TH ST
FORT LAUDERDALE FL
33301-1325
US

V. Phone/Fax

Practice location:
  • Phone: 954-800-2686
  • 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 Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: BENJAMIN MARCHANT
Title or Position: OWNER
Credential:
Phone: 206-618-5560