Provider Demographics
NPI:1992100952
Name:ACTIVE COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:ACTIVE COMMUNITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:WRIGHT
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:954-937-6306
Mailing Address - Street 1:1000 N HIATUS RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33026-3097
Mailing Address - Country:US
Mailing Address - Phone:954-937-6306
Mailing Address - Fax:954-450-2419
Practice Address - Street 1:1000 N HIATUS RD
Practice Address - Street 2:SUITE 140
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33026-3097
Practice Address - Country:US
Practice Address - Phone:954-937-6306
Practice Address - Fax:954-450-2419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-01
Last Update Date:2014-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH 9898251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMH 9898OtherREGISTERED MENTAL HEALTH COUNSELOR INTERN