=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639574171
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUNSELING CENTER FOR GROWTH AND RECOVERY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2014
-----------------------------------------------------
Last Update Date | 07/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 E LINTON BLVD SUITE 155A
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33483-3327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-404-1482
-----------------------------------------------------
Fax | 561-819-9822
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 603 ANDREWS AVE
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33483-7207
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-302-0701
-----------------------------------------------------
Fax | 561-819-9822
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. IRVING SCHATTNER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 561-302-0701
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW11390
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------