=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275038473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JUST BE THERAPEUTIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/28/2018
-----------------------------------------------------
Last Update Date | 09/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 HOLLYWOOD BLVD STE 104
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33020-6615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-353-4622
-----------------------------------------------------
Fax | 954-944-5937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2131 HOLLYWOOD BLVD STE 405
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33020-6787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-353-4622
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST/DIRECTOR
-----------------------------------------------------
Name | SHENIQUA DONES-WALLACE
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 786-353-4622
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH13004
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------