Provider Demographics
NPI:1366790552
Name:NOVA SOUTHEASTERN UNIVERSITY
Entity type:Organization
Organization Name:NOVA SOUTHEASTERN UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO/DIVISION OF CLINICAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:S
Authorized Official - Last Name:OLLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:954-262-4399
Mailing Address - Street 1:PO BOX 290250
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0250
Mailing Address - Country:US
Mailing Address - Phone:954-262-4334
Mailing Address - Fax:954-262-3882
Practice Address - Street 1:3526 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2002
Practice Address - Country:US
Practice Address - Phone:954-262-5730
Practice Address - Fax:954-262-3855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Multi-Specialty