=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801218078
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXCEPTIONAL MINDS CHILD & ADOLESCENTS THERAPEUTIC SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2014
-----------------------------------------------------
Last Update Date | 04/29/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 667 N BISCAYNE RIVER DR
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33169-6215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-423-7140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 80 SW 8TH ST
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33130-3003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-423-7013
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ANTONIO JOHNSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-423-7140
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------