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General NPI Number Information
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NPI Number | 1336622489
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Entity Type | Organization
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Legal Business Name | MENTAL WELLNESS CLINIC, LLC
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Dates
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Enumeration Date | 09/13/2018
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Last Update Date | 09/13/2018
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Provider Practice Location Address
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Address Line | 3580 MYSTIC POINTE DR
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City | AVENTURA
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State | FL
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Zip | 33180-2554
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Country | US
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Telephone | 786-708-7166
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Fax |
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Provider Business Mailing Address
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Address Line | 309 S 57TH TER
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City | HOLLYWOOD
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State | FL
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Zip | 33023-1426
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Country | US
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Telephone | 305-338-4027
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | NICOLE BERRY
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Credential | LMHC
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Telephone | 305-338-4027
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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