Provider Demographics
NPI:1790224624
Name:ACTUAL PSYCH GROUP LLC
Entity Type:Organization
Organization Name:ACTUAL PSYCH GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LISET
Authorized Official - Middle Name:
Authorized Official - Last Name:FIALLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-283-5497
Mailing Address - Street 1:1421 SW 124TH CT
Mailing Address - Street 2:APT C
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33184-2605
Mailing Address - Country:US
Mailing Address - Phone:305-283-5497
Mailing Address - Fax:
Practice Address - Street 1:33 W 26TH ST
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33010-1707
Practice Address - Country:US
Practice Address - Phone:305-887-4163
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-12
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW140951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty