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General NPI Number Information
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NPI Number | 1275689812
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Entity Type | Organization
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Legal Business Name | SERENITY COUNSELING SERVICES PA
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Dates
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Enumeration Date | 01/26/2007
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Last Update Date | 10/23/2012
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Provider Practice Location Address
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Address Line | 500 NW DIXIE HWY SUITE 102
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City | STUART
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State | FL
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Zip | 34994
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Country | US
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Telephone | 772-692-8585
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Fax | 772-692-5651
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Provider Business Mailing Address
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Address Line | PO BOX 2474
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City | STUART
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State | FL
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Zip | 34995
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Country | US
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Telephone | 772-692-8585
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Fax | 772-692-5651
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Authorized Official
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Title or Position | PSYCHOLOGIST
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Name | GILDA G BROADWELL
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Credential | PHD
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Telephone | 772-692-8585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PY5591
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number | 1943AD620400
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License Number State | FL
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