Healthcare Provider Details

I. General information

NPI: 1518351824
Provider Name (Legal Business Name): BREVARD PSYCHOLOGICAL ASSOCIATES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2015
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 S APOLLO BLVD
MELBOURNE FL
32901-4407
US

IV. Provider business mailing address

1611 SOUTH APOLLO BLVD.
MELBOURNE FL
32901
US

V. Phone/Fax

Practice location:
  • Phone: 321-724-2444
  • Fax: 321-952-4131
Mailing address:
  • Phone: 321-724-2444
  • Fax: 321-952-4131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPY4790
License Number StateFL

VIII. Authorized Official

Name: DR. TIMOTHY C SHORT, PSY. D
Title or Position: OWNER
Credential: PSYCHOLOGIST
Phone: 321-724-2444