Healthcare Provider Details

I. General information

NPI: 1245566165
Provider Name (Legal Business Name): RALSTON VICTOR BROWN LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6900 TURKEY LAKE RD STE 1-2
ORLANDO FL
32819-4707
US

IV. Provider business mailing address

6900 TURKEY LAKE RD STE 1-2
ORLANDO FL
32819-4707
US

V. Phone/Fax

Practice location:
  • Phone: 407-370-5357
  • Fax: 407-801-5139
Mailing address:
  • Phone: 73-705-3574
  • Fax: 407-801-5139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11008
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: