Provider Demographics
NPI:1275689812
Name:SERENITY COUNSELING SERVICES PA
Entity Type:Organization
Organization Name:SERENITY COUNSELING SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:GILDA
Authorized Official - Middle Name:G
Authorized Official - Last Name:BROADWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:772-692-8585
Mailing Address - Street 1:PO BOX 2474
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34995
Mailing Address - Country:US
Mailing Address - Phone:772-692-8585
Mailing Address - Fax:772-692-5651
Practice Address - Street 1:500 NW DIXIE HWY
Practice Address - Street 2:SUITE 102
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994
Practice Address - Country:US
Practice Address - Phone:772-692-8585
Practice Address - Fax:772-692-5651
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5591103T00000X
FL1943AD620400261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15-43-AD-6204-00OtherC&F SUB ABUSE COUNSELING
FL15-43-AD-6204-00OtherC&F SUB ABUSE COUNSELING