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General NPI Number Information
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NPI Number | 1053121558
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Entity Type | Organization
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Legal Business Name | PC PC MB2 LLC
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Dates
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Enumeration Date | 01/08/2025
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Last Update Date | 01/08/2025
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Provider Practice Location Address
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Address Line | 6750 N ANDREWS AVE # 2147
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City | FORT LAUDERDALE
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State | FL
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Zip | 33309-2173
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Country | US
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Telephone | 954-951-2936
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Fax |
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Provider Business Mailing Address
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Address Line | 6750 N ANDREWS AVE # 2147
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City | FORT LAUDERDALE
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State | FL
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Zip | 33309-2173
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MICHAEL BLAKE-EDWARDS
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Credential | LMHC
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Telephone | 954-951-2936
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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