=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821597238
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WINDSONG WELLNESS CENTER FOR RECOVERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2018
-----------------------------------------------------
Last Update Date | 02/12/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1914 SE PORT ST LUCIE BLVD
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34952-5514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-349-0218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1238 SW AVENS ST
-----------------------------------------------------
City | PORT SAINT LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34983-2506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-252-2107
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | BRETT LIEBERMAN
-----------------------------------------------------
Credential | LMFT
-----------------------------------------------------
Telephone | 772-349-0218
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------