=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154650620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MISTY MOUNTAIN FAMILY ENRICHMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2009
-----------------------------------------------------
Last Update Date | 08/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24840 BURNT PINE DR SUITES 1 & 2
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-2999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-301-4464
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24840 BURNT PINE DR SUITES 1 & 2
-----------------------------------------------------
City | BONITA SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34134-2999
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-301-4464
-----------------------------------------------------
Fax | 503-684-6289
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. GREGORY ALAN HASEK
-----------------------------------------------------
Credential | MA/MFT LPC, LMHC
-----------------------------------------------------
Telephone | 239-301-4464
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | MH 13637
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------