=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316481740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BARBARA GHEN PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2016
-----------------------------------------------------
Last Update Date | 12/04/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12128 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-5575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-592-7740
-----------------------------------------------------
Fax | 352-592-7742
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12128 CORTEZ BLVD
-----------------------------------------------------
City | BROOKSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34613-5575
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-592-7740
-----------------------------------------------------
Fax | 352-592-7742
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LCSW
-----------------------------------------------------
Name | BARBARA GHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-592-7740
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number | 5962
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------