Provider Demographics
NPI:1679234991
Name:THERVIL, ELODIE WELCH
Entity Type:Individual
Prefix:MRS
First Name:ELODIE
Middle Name:WELCH
Last Name:THERVIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 SW 52ND AVE UNIT 705
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33023-6911
Mailing Address - Country:US
Mailing Address - Phone:954-822-0473
Mailing Address - Fax:
Practice Address - Street 1:7875 NW 12TH ST STE 109
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1815
Practice Address - Country:US
Practice Address - Phone:786-269-3502
Practice Address - Fax:305-468-6154
Is Sole Proprietor?:No
Enumeration Date:2022-01-08
Last Update Date:2022-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician