=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629721147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY CONNECTIONS FOR LIFE, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2022
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1293 NW 40TH AVE
-----------------------------------------------------
City | LAUDERHILL
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33313-5801
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-657-3276
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18441 NW 2ND AVE STE 505
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-4562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-657-3276
-----------------------------------------------------
Fax | 786-565-9193
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TONYA LYNN ROBINSON
-----------------------------------------------------
Credential | BS
-----------------------------------------------------
Telephone | 786-657-3276
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------