Healthcare Provider Details

I. General information

NPI: 1730284530
Provider Name (Legal Business Name): BRANDON M HOUK LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 N PONCE DE LEON BLVD STE 4
ST AUGUSTINE FL
32084-2650
US

IV. Provider business mailing address

2200 N PONCE DE LEON BLVD STE 4
ST AUGUSTINE FL
32084-2650
US

V. Phone/Fax

Practice location:
  • Phone: 208-716-0425
  • Fax:
Mailing address:
  • Phone: 208-716-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC3487
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12288
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: