=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770058893
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCHOTHERAPY SPECIALISTS OF THE PALM BEACHES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2018
-----------------------------------------------------
Last Update Date | 10/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 PLAZA REAL S STE 226
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-4865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 531-313-5735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 PLAZA REAL S STE 226
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33432-4865
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 531-313-5735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING
-----------------------------------------------------
Name | STEPHANIE INGENITO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 570-352-3063
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------