MEDICARE: TRINITY HARBOR THERAPEUTIC SERVICES, INC.

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	302R00000X	Health Maintenance Organization	SW8335	FL
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1164535092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRINITY HARBOR THERAPEUTIC SERVICES, INC.

Provider Business Mailing Address
First Line	:	7401 WILES RD
Second Line	:	SUITE 150
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-2036
Country	:	US
Telephone Number	:	954-341-7774
Fax Number	:	480-287-9456

Provider Business Practice Location Address
First Line	:	7401 WILES RD
Second Line	:	SUITE 150
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33067-2036
Country	:	US
Telephone Number	:	954-341-7774
Fax Number	:	480-287-9456

Authorized Official
Title or Position	:	CLINICAL THERAPIST
Name	:	MRS. SHAWN MICHELLE GORDON
Credential	:	LCSW
Telephone Number	:	954-341-7774

Provider Enumeration Date	:	08/16/2006
Last Update Date	:	02/03/2009

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