=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255075123
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT ALLEN BAILEY LCSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2022
-----------------------------------------------------
Last Update Date | 10/23/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7520 NW 5TH ST STE 200
-----------------------------------------------------
City | PLANTATION
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33317-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 754-300-2972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5845 BLUEBERRY CT
-----------------------------------------------------
City | LAUDERHILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33313-3081
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-931-6968
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 0904017546
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW22943
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------