MEDICARE: ANGEL CLINICAL THERAPY OF BROWARD 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1588448625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ANGEL CLINICAL THERAPY OF BROWARD LLC

Provider Business Mailing Address
First Line	:	4961 SW 148TH AVE
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33330-2419
Country	:	US
Telephone Number	:	786-663-2822
Fax Number	:

Provider Business Practice Location Address
First Line	:	4961 SW 148TH AVE
Second Line	:
City	:	DAVIE
State	:	FL
Zip	:	33330-2419
Country	:	US
Telephone Number	:	786-663-2822
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ALEXANDRA CODECIDO
Credential	:
Telephone Number	:	786-663-2822

Provider Enumeration Date	:	08/21/2023
Last Update Date	:	08/21/2023

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