Provider Demographics
NPI:1982059861
Name:FORT LAUDERDALE DBT
Entity type:Organization
Organization Name:FORT LAUDERDALE DBT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ETTINGER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:973-224-0693
Mailing Address - Street 1:3029 NE 188TH ST
Mailing Address - Street 2:APT. 516
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33180-2989
Mailing Address - Country:US
Mailing Address - Phone:973-224-0693
Mailing Address - Fax:
Practice Address - Street 1:2627 NE 203RD ST
Practice Address - Street 2:SUITE 214
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33180-1900
Practice Address - Country:US
Practice Address - Phone:973-224-0693
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW12668101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty