Healthcare Provider Details

I. General information

NPI: 1093298457
Provider Name (Legal Business Name): MELTING WALLS FAMILY CONSULTANTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 TOWN PLAZA CT STE 1010
WINTER SPRINGS FL
32708-6231
US

IV. Provider business mailing address

1809 E BROADWAY ST STE 355
OVIEDO FL
32765-8597
US

V. Phone/Fax

Practice location:
  • Phone: 407-953-2497
  • Fax: 407-359-2756
Mailing address:
  • Phone: 407-953-2497
  • Fax: 407-359-2756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN TURNER
Title or Position: BUSINESS OPERATIONS
Credential: PHD
Phone: 407-953-7927