Provider Demographics
NPI:1508648072
Name:AZUL MINDSPACE LLC
Entity Type:Organization
Organization Name:AZUL MINDSPACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:786-505-4022
Mailing Address - Street 1:10631 HABITAT TRL
Mailing Address - Street 2:
Mailing Address - City:BOKEELIA
Mailing Address - State:FL
Mailing Address - Zip Code:33922-3122
Mailing Address - Country:US
Mailing Address - Phone:786-505-4022
Mailing Address - Fax:
Practice Address - Street 1:10631 HABITAT TRL
Practice Address - Street 2:
Practice Address - City:BOKEELIA
Practice Address - State:FL
Practice Address - Zip Code:33922-3122
Practice Address - Country:US
Practice Address - Phone:786-505-4022
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty