=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811927262
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX CLINIC INC OF BROWARD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 08/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2212 SW 60TH TERRACE
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-491-2133
-----------------------------------------------------
Fax | 954-491-2344
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2212 SW 60TH TERRACE
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-491-2133
-----------------------------------------------------
Fax | 954-491-2344
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | BONNIE GRAHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 305-891-3439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 1006AD354501
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------