Healthcare Provider Details

I. General information

NPI: 1841115532
Provider Name (Legal Business Name): EVENTIDE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 ORANGE WOODS BLVD
ROCKLEDGE FL
32955-4309
US

IV. Provider business mailing address

1000 ORANGE WOODS BLVD
ROCKLEDGE FL
32955-4309
US

V. Phone/Fax

Practice location:
  • Phone: 321-408-4213
  • Fax:
Mailing address:
  • Phone: 321-408-4213
  • Fax:

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: JEANNINE HANEY-FRYBERGER
Title or Position: SOLE PROPRIETOR
Credential: LMHC
Phone: 321-408-4213