Provider Demographics
NPI:1063388858
Name:PHANOR, WOLSELEY
Entity type:Individual
Prefix:
First Name:WOLSELEY
Middle Name:
Last Name:PHANOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16265 NE 8TH CT
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4405
Mailing Address - Country:US
Mailing Address - Phone:786-929-7116
Mailing Address - Fax:
Practice Address - Street 1:16265 NE 8TH CT
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4405
Practice Address - Country:US
Practice Address - Phone:786-929-7116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-16
Last Update Date:2025-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-25-482184103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst