Healthcare Provider Details

I. General information

NPI: 1215393400
Provider Name (Legal Business Name): SANCTUARY AT WINDSONG, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2016
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2806 S US HIGHWAY 1 C7
FORT PIERCE FL
34982-8109
US

IV. Provider business mailing address

1238 SW AVENS STREET
PORT SAINT LUCIE FL
34983
US

V. Phone/Fax

Practice location:
  • Phone: 772-465-4044
  • Fax:
Mailing address:
  • Phone: 863-877-6757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberMT2766
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMT2766
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT2766
License Number StateFL

VIII. Authorized Official

Name: BRETT LIEBERMAN
Title or Position: CEO
Credential: LMFT
Phone: 772-465-4044