Provider Demographics
NPI:1265683551
Name:ENSO PSYCH GROUP, LLC
Entity Type:Organization
Organization Name:ENSO PSYCH GROUP, LLC
Other - Org Name:MIAMI MENTAL HEALTH ASSOCIATES, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:SION
Authorized Official - Middle Name:
Authorized Official - Last Name:DOMAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:850-778-1642
Mailing Address - Street 1:1113 S MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-4659
Mailing Address - Country:US
Mailing Address - Phone:850-778-1642
Mailing Address - Fax:
Practice Address - Street 1:1113 S MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-4659
Practice Address - Country:US
Practice Address - Phone:850-778-1642
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001964700Medicaid