=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790002624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CFB LCSW INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2010
-----------------------------------------------------
Last Update Date | 05/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3501 KEYSER AVE 3
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-2459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-707-7774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3501 KEYSER AVE 3
-----------------------------------------------------
City | HOLLYWOOD
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33021-2459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-707-7774
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRES
-----------------------------------------------------
Name | MR. CARLOS FERNANDEZ BETHART
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 954-707-7774
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW8535
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------