Healthcare Provider Details

I. General information

NPI: 1730828286
Provider Name (Legal Business Name): BREVARD PSYCHIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2022
Last Update Date: 08/31/2022
Certification Date: 08/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

759 GLENGARRY DR
MELBOURNE FL
32940-1867
US

IV. Provider business mailing address

759 GLENGARRY DR
MELBOURNE FL
32940-1867
US

V. Phone/Fax

Practice location:
  • Phone: 801-609-8388
  • Fax: 801-797-0245
Mailing address:
  • Phone: 801-609-8388
  • Fax: 801-797-0245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSEPH SIN
Title or Position: PRESIDENT
Credential:
Phone: 801-609-8388