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General NPI Number Information
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NPI Number | 1821343146
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Entity Type | Organization
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Legal Business Name | DELRAY BEACH INTENSIVE OUTPATIENT PROGRAM LLC
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Dates
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Enumeration Date | 07/24/2012
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Last Update Date | 07/24/2012
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Provider Practice Location Address
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Address Line | 301 W ATLANTIC AVE SUITE 0-5
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City | DELRAY BEACH
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State | FL
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Zip | 33444-3687
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Country | US
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Telephone | 561-894-6010
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Fax | 305-647-0680
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Provider Business Mailing Address
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Address Line | 301 W ATLANTIC AVE SUITE 0-5
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City | DELRAY BEACH
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State | FL
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Zip | 33444-3687
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Country | US
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Telephone | 561-894-6010
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Fax | 305-647-0680
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Authorized Official
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Title or Position | PRESIDENT
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Name | ALLEN SERGIO MCCORMICK
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Credential | PH.D, LCSW, CAP
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Telephone | 561-894-6010
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW3546
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License Number State | FL
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