Healthcare Provider Details

I. General information

NPI: 1518772847
Provider Name (Legal Business Name): PROGRESSIVE MENTAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2025
Last Update Date: 02/12/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 HIGHLAND ST
ORANGE CITY FL
32763
US

IV. Provider business mailing address

108 HIGHLAND ST
ORANGE CITY FL
32763-7017
US

V. Phone/Fax

Practice location:
  • Phone: 386-837-4387
  • Fax:
Mailing address:
  • Phone: 386-837-4387
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. CHRISTOPHER GAITOR
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: MSN APRN, PMHNP- BC
Phone: 386-837-4387