Provider Demographics
NPI:1245782176
Name:SOUTH FLORIDA NEURO WELLNESS CENTERS LLC
Entity Type:Organization
Organization Name:SOUTH FLORIDA NEURO WELLNESS CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MBR
Authorized Official - Phone:954-284-0025
Mailing Address - Street 1:6191 ORANGE DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-3449
Mailing Address - Country:US
Mailing Address - Phone:954-284-0025
Mailing Address - Fax:954-252-4037
Practice Address - Street 1:5337 ORANGE DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33314-3815
Practice Address - Country:US
Practice Address - Phone:954-284-0025
Practice Address - Fax:954-252-4037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-26
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3051101YM0800X
FLPY6992103G00000X, 103TC0700X
FLMT2760106H00000X
FL305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes305S00000XManaged Care OrganizationsPoint of Service
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL900940694Medicare UPIN