=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922766450
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIXTHERAPEUTIC SOLUTIONS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/01/2021
-----------------------------------------------------
Last Update Date | 12/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2901 CLINT MOORE RD STE 2-1001
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33496-2041
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-870-0475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10385 MILBURN LN
-----------------------------------------------------
City | BOCA RATON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33498-4609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-870-0475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF BILLING
-----------------------------------------------------
Name | VERONICA HERNANDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 954-203-3584
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------