=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053064675
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENTALLY PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/02/2022
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10689 N KENDALL DR STE 211
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33176-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-204-9499
-----------------------------------------------------
Fax | 507-607-8720
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10689 N KENDALL DR STE 211
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33176-1594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-204-9499
-----------------------------------------------------
Fax | 507-607-8720
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. JOSE GABRIEL VALDES
-----------------------------------------------------
Credential | DNP, APRN, PMHNP-BC
-----------------------------------------------------
Telephone | 786-208-0065
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------