MEDICARE: MARCHANT HALSOR LLC ELLIE MENTAL HEALTH

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
2	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346967122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARCHANT HALSOR LLC ELLIE MENTAL HEALTH

Provider Business Mailing Address
First Line	:	1703 NE 5TH ST
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33301-1325
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2853 EXECUTIVE PARK DR
Second Line	:
City	:	WESTON
State	:	FL
Zip	:	33331-3656
Country	:	US
Telephone Number	:	954-800-2686
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	BENJAMIN MARCHANT
Credential	:
Telephone Number	:	206-618-5560

Provider Enumeration Date	:	10/24/2022
Last Update Date	:	05/10/2024

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