Healthcare Provider Details

I. General information

NPI: 1134573512
Provider Name (Legal Business Name): TREASURE COAST PSYCHOLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 SW FEDERAL HWY STE 200B
STUART FL
34994-2952
US

IV. Provider business mailing address

819 SW FEDERAL HWY STE 200B
STUART FL
34994-2952
US

V. Phone/Fax

Practice location:
  • Phone: 561-531-8356
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License NumberPY 9495
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License NumberPY 9495
License Number StateFL

VIII. Authorized Official

Name: DR. JIMMY L MIDDLEBROOK
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 561-531-8356