MEDICARE: HEALTHY MINDS HEALTHY HEARTS THERAPEUTIC SERVICES, 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	1041C0700X	Clinical Social Worker	SW14731	FL

General Provider Information

NPI Number	:	1154820926
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHY MINDS HEALTHY HEARTS THERAPEUTIC SERVICES, LLC

Provider Business Mailing Address
First Line	:	7958 PINES BLVD UNIT 324
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33024-6918
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11820 MIRAMAR PKWY STE 304
Second Line	:
City	:	MIRAMAR
State	:	FL
Zip	:	33025-5820
Country	:	US
Telephone Number	:	954-225-4148
Fax Number	:

Authorized Official
Title or Position	:	LICENSED CLINICAL SOCIAL WORKER
Name	:	LATHOSHA ALEXANDER
Credential	:	LSCW
Telephone Number	:	954-445-4048

Provider Enumeration Date	:	02/07/2018
Last Update Date	:	02/07/2018

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