=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659803773
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACE OF MIND MENTAL HEALTH SERVICES CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2017
-----------------------------------------------------
Last Update Date | 03/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7356 JACARANDA LANE
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-252-9131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7356 JACARANDA LANE
-----------------------------------------------------
City | MIAMI LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-252-9131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MARIA ESTHER MEDINA
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 786-252-9131
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | MH10200
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------