=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356877047
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMARITAN COUNSELING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2017
-----------------------------------------------------
Last Update Date | 05/02/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 SE 3RD AVENUE
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-401-8527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6760 N PINE ISLAND RD
-----------------------------------------------------
City | TAMARAC
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33321-3715
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-401-8527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | MR. MALLICA DAVID REYNOLDS
-----------------------------------------------------
Credential | MS. LMFT
-----------------------------------------------------
Telephone | 561-401-8527
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | MT3178
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------