Provider Demographics
NPI:1619352283
Name:125TH STREET NM CORP
Entity Type:Organization
Organization Name:125TH STREET NM CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CDO
Authorized Official - Prefix:
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUTHAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-271-0485
Mailing Address - Street 1:505 NE 125TH ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33161-4718
Mailing Address - Country:US
Mailing Address - Phone:954-271-0485
Mailing Address - Fax:
Practice Address - Street 1:505 NE 125TH ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33161-4718
Practice Address - Country:US
Practice Address - Phone:954-271-0485
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 2084P0802X
FLPMC20261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHCC8934OtherACHA