=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043085103
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIBEWELL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2023
-----------------------------------------------------
Last Update Date | 04/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 126 HIGHLAND ST
-----------------------------------------------------
City | COCOA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32922-7523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-361-8227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 126 HIGHLAND ST
-----------------------------------------------------
City | COCOA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32922-7523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-361-8227
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | MICHELLE CHAFFARDET
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 305-970-5519
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------