Provider Demographics
NPI:1851698682
Name:SEALIFE PSYCHIATRIC SERVICES INC
Entity Type:Organization
Organization Name:SEALIFE PSYCHIATRIC SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP, PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:ROXANE
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, ARNP-BC
Authorized Official - Phone:954-851-9690
Mailing Address - Street 1:14201 W SUNRISE BLVD
Mailing Address - Street 2:STE 208
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-3207
Mailing Address - Country:US
Mailing Address - Phone:954-851-9690
Mailing Address - Fax:954-851-9688
Practice Address - Street 1:14201 W SUNRISE BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-3207
Practice Address - Country:US
Practice Address - Phone:954-851-9690
Practice Address - Fax:954-851-9688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-14
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9312887363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLEW721AMedicare Oscar/Certification