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General NPI Number Information
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NPI Number | 1003348855
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Entity Type | Organization
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Legal Business Name | CENTER FOR BEHAVIORAL MEDICINE
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Dates
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Enumeration Date | 03/31/2017
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Last Update Date | 03/31/2017
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Provider Practice Location Address
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Address Line | 1730 DUNLAWTON AVE SUITE 3
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City | PORT ORANGE
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State | FL
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Zip | 32127-8985
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Country | US
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Telephone | 138-695-7390
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Fax |
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Provider Business Mailing Address
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Address Line | 1730 DUNLAWTON AVE SUITE 3
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City | PORT ORANGE
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State | FL
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Zip | 32127-8985
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | SHANE PORTER
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Credential |
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Telephone | 13869573905
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH6409
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License Number State | FL
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