MEDICARE: SUNSHINY MENTAL HEALTH PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084B0040X	Behavioral Neurology & Neuropsychiatry Physician	ME109705	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	130080684	OTHER	CO	DRIVERS LICENSE

General Provider Information

NPI Number	:	1023448388
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUNSHINY MENTAL HEALTH PLLC

Provider Business Mailing Address
First Line	:	PO BOX 451959
Second Line	:
City	:	SUNRISE
State	:	FL
Zip	:	33345-1959
Country	:	US
Telephone Number	:	720-515-9112
Fax Number	:	888-958-5968

Provider Business Practice Location Address
First Line	:	19330 SW 69TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33332-1652
Country	:	US
Telephone Number	:	754-666-1911
Fax Number	:	888-958-5968

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KHAJA CHISTY
Credential	:	MD
Telephone Number	:	248-987-8117

Provider Enumeration Date	:	11/22/2013
Last Update Date	:	09/20/2018

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