MEDICARE: PALMCOAST THERAPY, 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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1780271254
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PALMCOAST THERAPY, INC.

Provider Business Mailing Address
First Line	:	2598 E SUNRISE BLVD STE 210-A
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-3230
Country	:	US
Telephone Number	:	954-309-3449
Fax Number	:

Provider Business Practice Location Address
First Line	:	2598 E SUNRISE BLVD STE 210-A
Second Line	:
City	:	FT LAUDERDALE
State	:	FL
Zip	:	33304-3230
Country	:	US
Telephone Number	:	954-309-3449
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	ANDREA CAROLINE MALLEN
Credential	:	LCSW
Telephone Number	:	954-309-3449

Provider Enumeration Date	:	12/30/2020
Last Update Date	:	12/30/2020

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