1306068622 NPI number — EAST LAS OLAS PSYCHOLOGICAL GROUP

Table of content: VANIETY CHERELLE REID HAIR PRACTITIONER (NPI 1851714182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306068622 NPI number — EAST LAS OLAS PSYCHOLOGICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST LAS OLAS PSYCHOLOGICAL GROUP
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:
1306068622
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:
108 SE 8TH AVENUE, SUITE 203
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT LAUDERDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33140
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-768-0434
Provider Business Mailing Address Fax Number:
954-768-0285

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
108 SE 8TH AVENUE, SUITE 203
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT LAUDERDALE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-768-0434
Provider Business Practice Location Address Fax Number:
954-768-0285
Provider Enumeration Date:
05/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DEL PRETE
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
964-768-0434

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  MENTAL HEALTH 1856 , 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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