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General NPI Number Information
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NPI Number | 1710372495
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Entity Type | Organization
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Legal Business Name | BREVARD FAMILY WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 03/31/2015
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 2460 N COURTENAY PKWY STE 114
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-4101
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Country | US
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Telephone | 321-615-1741
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Fax |
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Provider Business Mailing Address
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Address Line | 2460 N COURTENAY PKWY STE 114
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City | MERRITT ISLAND
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State | FL
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Zip | 32953-4101
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Country | US
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Telephone | 321-615-1741
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Fax |
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Authorized Official
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Title or Position | OWNER, LMFT
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Name | JESSICA STEBBINS
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Credential | LMFT
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Telephone | 321-615-1741
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MT2696
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License Number State | FL
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