MEDICARE: MOTIVATIONAL INSTITUTE FOR BEHAVIORAL HEALTH, 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	103TC0700X	Clinical Psychologist	PY9326	FL

General Provider Information

NPI Number	:	1134598162
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOTIVATIONAL INSTITUTE FOR BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	2425 E COMMERCIAL BLVD
Second Line	:	SUITE 301
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4034
Country	:	US
Telephone Number	:	954-606-5088
Fax Number	:	954-616-5147

Provider Business Practice Location Address
First Line	:	2425 E COMMERCIAL BLVD
Second Line	:	SUITE 301
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33308-4034
Country	:	US
Telephone Number	:	954-606-5088
Fax Number	:	954-616-5147

Authorized Official
Title or Position	:	LICENSED PSYCHOLOGIST
Name	:	DR. MARCY JASLOW
Credential	:	PSY.D.
Telephone Number	:	954-616-5088

Provider Enumeration Date	:	09/21/2015
Last Update Date	:	09/21/2015

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