=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578909131
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIND, BODY AND SOUL COUNSELING SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2013
-----------------------------------------------------
Last Update Date | 06/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8180 NW 36TH ST SUITE 100-C
-----------------------------------------------------
City | DORAL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33166-6645
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-753-2671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4727 NW 4TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33126-2113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-753-2671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | GISELLE CARIDAD MALLON
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 305-753-2671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LMHC 9366
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------