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General NPI Number Information
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NPI Number | 1922563634
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Entity Type | Organization
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Legal Business Name | AUTHENTIC INTEGRATIVE WELLNESS INC
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Dates
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Enumeration Date | 02/06/2019
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Last Update Date | 03/20/2019
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Provider Practice Location Address
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Address Line | 2003 W CYPRESS CREEK RD STE 103
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City | FORT LAUDERDALE
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State | FL
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Zip | 33309-1834
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Country | US
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Telephone | 954-616-5246
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Fax |
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Provider Business Mailing Address
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Address Line | 2003 W CYPRESS CREEK RD STE 103
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City | FORT LAUDERDALE
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State | FL
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Zip | 33309-1834
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Country | US
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Telephone | 954-616-5246
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Fax | 754-701-6433
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JESSICA VERA
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Credential | PHD
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Telephone | 954-616-5246
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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