Basic Information
| Provider Information | |||||||||
| NPI: | 1316456387 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUMMAGE | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4740 N STATE ROAD 7 | ||||||||
| Address2: | |||||||||
| City: | LAUDERDALE LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333195839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544864005 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 590 NW PEACOCK BLVD STE 10 | ||||||||
| Address2: | |||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349862213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723616767 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2017 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | MH15388 | FL | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 101YM0800X | MH15388 | FL | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.