=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205402344
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FENIX MENTAL HEALTH GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2021
-----------------------------------------------------
Last Update Date | 11/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 SW 27TH AVE STE 505
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33145-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-633-6362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1800 SW 27TH AVE STE 505
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33145-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-633-6362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DUNIA REYES HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-542-9914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------