Provider Demographics
NPI:1487157715
Name:AUTHENTIC BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:AUTHENTIC BEHAVIORAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYDIA
Authorized Official - Middle Name:ROSA
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-715-5477
Mailing Address - Street 1:18459 PINES BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1400
Mailing Address - Country:US
Mailing Address - Phone:954-715-5477
Mailing Address - Fax:
Practice Address - Street 1:9050 PINES BLVD STE 450-00
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6455
Practice Address - Country:US
Practice Address - Phone:954-715-5477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10094103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty