Provider Demographics
NPI:1952086928
Name:INNER DISCOVERY MENTAL HEALTH SERVICES, PLLC
Entity Type:Organization
Organization Name:INNER DISCOVERY MENTAL HEALTH SERVICES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ PSYCHIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAACK
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:786-499-2926
Mailing Address - Street 1:4474 WESTON RD # 1097
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33331-3195
Mailing Address - Country:US
Mailing Address - Phone:754-333-1765
Mailing Address - Fax:
Practice Address - Street 1:4848 GRAPEVINE WAY
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33331-3358
Practice Address - Country:US
Practice Address - Phone:786-499-2926
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1295253870Medicaid