=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497056329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPPORTIVE HEALTH SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2010
-----------------------------------------------------
Last Update Date | 11/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9400 SW 52ND TER
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-6408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-273-9526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9400 SW 52ND TER
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33165-6408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-273-9526
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. LOURDES O. FERRER
-----------------------------------------------------
Credential | L.C.S.W.
-----------------------------------------------------
Telephone | 305-273-9526
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW3889
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------