=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750504452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PORTIA J NEWBOLD LMHC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1469 NW 36 STREET NEW HORIZONS COMMUNITY MENTAL HEALTH CENTER INC
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-635-7444
-----------------------------------------------------
Fax | 305-635-6378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14725 NE 5TH COURT
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-948-2369
-----------------------------------------------------
Fax | 305-948-2369
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH8866
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------