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General NPI Number Information
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NPI Number | 1033587795
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Entity Type | Organization
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Legal Business Name | INDIVIDUAL PROVIDER
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Dates
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Enumeration Date | 09/10/2015
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Last Update Date | 09/10/2015
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Provider Practice Location Address
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Address Line | 650 PALERMO VISTA CT
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City | LONGWOOD
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State | FL
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Zip | 32750-3419
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Country | US
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Telephone | 317-697-8932
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Fax |
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Provider Business Mailing Address
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Address Line | 650 PALERMO VISTA CT
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City | LONGWOOD
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State | FL
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Zip | 32750-3419
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Country | US
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Telephone | 317-697-8932
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Fax |
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Authorized Official
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Title or Position | MASTER'S LEVEL CONTRACT CLINICIAN
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Name | MS. CHRISTINE MARIE GARRY
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Credential |
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Telephone | 317-697-8932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | ISW10093
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License Number State | FL
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