=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740875764
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HERITAGE BEHAVIORAL HEALTH & WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2021
-----------------------------------------------------
Last Update Date | 03/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2620 NORTH AUSTRALIAN AVENUE STE 109
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33407-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-316-7430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3900 HAVERHILL RD N UNIT 223141
-----------------------------------------------------
City | WEST PALM BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33422-5101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-316-7430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LMHC
-----------------------------------------------------
Name | NITYIA L LATHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-316-7430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------