MEDICARE: TOTAL MENTAL WELLNESS

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	261QM0850X	Adult Mental Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1346676004	OTHER	FL	NPI

General Provider Information

NPI Number	:	1093344947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TOTAL MENTAL WELLNESS

Provider Business Mailing Address
First Line	:	500 E BROWARD BLVD # 1701
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33394-3000
Country	:	US
Telephone Number	:	954-848-2814
Fax Number	:

Provider Business Practice Location Address
First Line	:	500 E BROWARD BLVD # 1701
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33394-3000
Country	:	US
Telephone Number	:	954-848-2814
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. AUDREY LA NOCE
Credential	:	DO
Telephone Number	:	954-848-2814

Provider Enumeration Date	:	04/03/2020
Last Update Date	:	04/03/2020

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