Basic Information
| Provider Information | |||||||||
| NPI: | 1285760702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARCUS | ||||||||
| FirstName: | PHYLLIS | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRAMER | ||||||||
| OtherFirstName: | PHYLLIS | ||||||||
| OtherMiddleName: | JANE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 635 SW 14TH TER APT 8 | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333127280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543042399 | ||||||||
| FaxNumber: | 9544973857 | ||||||||
| Practice Location | |||||||||
| Address1: | 540 NW 165TH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331696304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7866486550 | ||||||||
| FaxNumber: | 7866486505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2007 | ||||||||
| LastUpdateDate: | 11/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH9698 | FL | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | MT2404 | FL | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 767784700 | 05 | FL | MEDICAID |