Provider Demographics
NPI:1821864505
Name:COLLECTIVE SELF LLC
Entity Type:Organization
Organization Name:COLLECTIVE SELF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GWENEVERE
Authorized Official - Middle Name:
Authorized Official - Last Name:ABRIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-240-0884
Mailing Address - Street 1:5379 LYONS RD # 172
Mailing Address - Street 2:
Mailing Address - City:COCONUT CREEK
Mailing Address - State:FL
Mailing Address - Zip Code:33073-2810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4400 W SAMPLE RD STE 112
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33073-3457
Practice Address - Country:US
Practice Address - Phone:954-240-0884
Practice Address - Fax:505-438-1820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-04
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty