Healthcare Provider Details

I. General information

NPI: 1770048555
Provider Name (Legal Business Name): MICHAEL D. GUSACK, MA, LMHC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E MIRACLE STRIP PKWY STE 602
MARY ESTHER FL
32569-1991
US

IV. Provider business mailing address

PO BOX 879
FORT WALTON BEACH FL
32549-0879
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-7035
  • Fax: 850-243-8529
Mailing address:
  • Phone: 850-243-7035
  • Fax: 850-243-8529

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MISS MARIA TUMANENG
Title or Position: ASSISTANT MANAGER/BILLING
Credential:
Phone: 850-384-8648