=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679928600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE COMMUNITY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2016
-----------------------------------------------------
Last Update Date | 04/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 NE 2ND ST
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-1037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-533-9818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1217 NE 3RD ST
-----------------------------------------------------
City | FORT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33301-1743
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-533-9818
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MS. JUDITH L BLOOM
-----------------------------------------------------
Credential | MSW, LMFT
-----------------------------------------------------
Telephone | 954-533-9818
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MT2236
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------