Healthcare Provider Details

I. General information

NPI: 1356919005
Provider Name (Legal Business Name): JUAN CARLOS VICENTE RMHCI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2021
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2233 N COMMERCE PKWY STE 3
WESTON FL
33326-3252
US

IV. Provider business mailing address

305 S KETCH DR
SUNRISE FL
33326-2240
US

V. Phone/Fax

Practice location:
  • Phone: 954-217-1757
  • Fax: 954-385-3807
Mailing address:
  • Phone: 757-230-6436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: