=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548631484
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROL WISHNOV LCSW LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2015
-----------------------------------------------------
Last Update Date | 12/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22722 MERIDIANA DR
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-6313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-289-2550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22722 MERIDIANA DR
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33433-6313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-289-2550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. CAROL ANN WISHNOV
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 561-289-2660
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW13177
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------