1003897489 NPI number — BROWARD MARRIAGE & FAMILY THERAPY, INC.

Table of content: (NPI 1003897489)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003897489 NPI number — BROWARD MARRIAGE & FAMILY THERAPY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BROWARD MARRIAGE & FAMILY THERAPY, INC.
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:
1003897489
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13469 NW 5TH CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PLANTATION
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33325-6110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-394-0351
Provider Business Mailing Address Fax Number:
954-746-5738

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4953 N UNIVERSITY DR
Provider Second Line Business Practice Location Address:
SUITE #14-B- LOS MADEROS PLAZA
Provider Business Practice Location Address City Name:
LAUDERHILL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33351-4506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-394-0351
Provider Business Practice Location Address Fax Number:
954-746-5738
Provider Enumeration Date:
11/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
EL-KOLALLI
Authorized Official First Name:
KAMELIA
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
MARRIAGE & FAMILY THERAPIST/OWNER
Authorized Official Telephone Number:
954-394-0351

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  MT1977 , 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)





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