Provider Demographics
NPI:1346408721
Name:SEAL THERAPEUTIC CORPORATION
Entity Type:Organization
Organization Name:SEAL THERAPEUTIC CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:561-715-5910
Mailing Address - Street 1:2735 SE 140TH PL
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-2877
Mailing Address - Country:US
Mailing Address - Phone:561-715-5910
Mailing Address - Fax:561-892-0268
Practice Address - Street 1:5818 SE AGNEW RD
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-4020
Practice Address - Country:US
Practice Address - Phone:561-715-5910
Practice Address - Fax:561-892-0268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
FLSW8553251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health