Healthcare Provider Details

I. General information

NPI: 1174886600
Provider Name (Legal Business Name): BRANDON PSYCHIATRY AND COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N PARSONS AVE SUITE 107 A
BRANDON FL
33510-4538
US

IV. Provider business mailing address

401 N PARSONS AVE SUITE 107 A
BRANDON FL
33510-4538
US

V. Phone/Fax

Practice location:
  • Phone: 813-967-1376
  • Fax: 813-681-5958
Mailing address:
  • Phone: 813-967-1376
  • Fax: 813-681-5958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number47310
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberBK4208016
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW5979
License Number StateFL

VIII. Authorized Official

Name: MS. ELENA ANNA SPANOS
Title or Position: PRESIDENT
Credential: M.S.W.
Phone: 813-967-1376