Basic Information
Provider Information | |||||||||
NPI: | 1992370977 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PELIKAN | ||||||||
FirstName: | VITO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMHC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4740 N STATE ROAD 7 | ||||||||
Address2: |   | ||||||||
City: | LAUDERDALE LAKES | ||||||||
State: | FL | ||||||||
PostalCode: | 333195839 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9544864005 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3301 COLLEGE AVE FL 3 | ||||||||
Address2: |   | ||||||||
City: | DAVIE | ||||||||
State: | FL | ||||||||
PostalCode: | 333147721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9544246911 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2021 | ||||||||
LastUpdateDate: | 09/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 115564 | FL | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | MH19175 | FL | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.