=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093256935
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KATHRYN DOLL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2017
-----------------------------------------------------
Last Update Date | 10/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9900 W SAMPLE RD STE 309
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33065-4048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-260-8667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8500 NW 79TH ST
-----------------------------------------------------
City | TAMARAC
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33321-1659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-260-8667
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/MANAGER
-----------------------------------------------------
Name | KATHRYN DOLL
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 954-260-8667
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | SW 14042
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------