Healthcare Provider Details

I. General information

NPI: 1689455149
Provider Name (Legal Business Name): 505 FAMILY THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1758 SIOUX TRL
GULF BREEZE FL
32563-9257
US

IV. Provider business mailing address

1758 SIOUX TRL
GULF BREEZE FL
32563-9257
US

V. Phone/Fax

Practice location:
  • Phone: 505-234-6262
  • Fax:
Mailing address:
  • Phone: 505-234-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: ANNALYSE LUCERO
Title or Position: OWNER
Credential: LMFT
Phone: 505-261-0923