1710489430 NPI number — THERAPY OUT THE BOX, LLC

Table of content: ELISA MARIE HICKMAN MSW, LICSW (NPI 1780227850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710489430 NPI number — THERAPY OUT THE BOX, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THERAPY OUT THE BOX, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710489430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
350 NW 134TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33028-2251
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-536-2319
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12251 TAFT ST STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-951-0974
Provider Business Practice Location Address Fax Number:
954-743-1915
Provider Enumeration Date:
03/08/2018

Additional Information

Authorized Official

Authorized Official Last Name:
MCMILLER TURNER
Authorized Official First Name:
LAINISHA
Authorized Official Middle Name:
Authorized Official Title or Position:
OCCUPATIONAL THERAPIST/OWNER
Authorized Official Telephone Number:
954-536-2319

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X , with the licence number:  11795 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 023979900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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