MEDICARE: PC PC MB2 LLC

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1053121558
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PC PC MB2 LLC

Provider Business Mailing Address
First Line	:	6750 N ANDREWS AVE # 2147
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-2173
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6750 N ANDREWS AVE # 2147
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33309-2173
Country	:	US
Telephone Number	:	954-951-2936
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MICHAEL BLAKE-EDWARDS
Credential	:	LMHC
Telephone Number	:	954-951-2936

Provider Enumeration Date	:	01/08/2025
Last Update Date	:	01/08/2025

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