Provider Demographics
NPI:1194240291
Name:INTROSPECTIVE, LLC
Entity type:Organization
Organization Name:INTROSPECTIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SONNY
Authorized Official - Middle Name:
Authorized Official - Last Name:ETIENNE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:754-281-0749
Mailing Address - Street 1:8400 N UNIVERSITY DR STE 114
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-1700
Mailing Address - Country:US
Mailing Address - Phone:954-774-2201
Mailing Address - Fax:
Practice Address - Street 1:8400 N UNIVERSITY DR STE 114
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33321-1700
Practice Address - Country:US
Practice Address - Phone:954-774-2201
Practice Address - Fax:954-827-0988
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty