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Provider Information for 1528446671

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1528446671

Calendar   Last Updated:  2015-05-09
  Certification Date: 


Name Value
NPI 1528446671
Enumeration Date 2015-05-09
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 1015 COUNTRY CLUB DR 401
MARGATE, FL 33063-3221
United States

Phone: 754-307-3075 | Fax: 305-412-0140
View Map External Link
Primary Practice Address 7811 CORAL WAY 106
MIAMI, FL 33155-6540
United States

Phone: 305-412-0138 | Fax: 305-412-0140
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 101YM0800X - Counselor Mental Health FL PMH1049