Basic Information
| Provider Information | |||||||||
| NPI: | 1275699621 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FLORIDA PERSONAL GROWTH CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3511 W COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547333394 | ||||||||
| FaxNumber: | 9547334483 | ||||||||
| Practice Location | |||||||||
| Address1: | 3511 W COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 305 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9547333394 | ||||||||
| FaxNumber: | 9547334483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | GLASSMAN | ||||||||
| AuthorizedOfficialFirstName: | CAREN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9547333394 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH 2998 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.