=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447879465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY BALANCE THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2020
-----------------------------------------------------
Last Update Date | 03/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8600 SW 212TH ST APT 210
-----------------------------------------------------
City | CUTLER BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33189-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-771-3370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8600 SW 212TH ST APT 210
-----------------------------------------------------
City | CUTLER BAY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33189-3812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-771-3370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. FLOR DE LIZ SANTIAGO FERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 786-263-3965
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------