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General NPI Number Information
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NPI Number | 1841816204
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Entity Type | Organization
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Legal Business Name | THE SOURCE BEHAVIORAL HEALTH, LLC
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Dates
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Enumeration Date | 06/22/2020
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Last Update Date | 09/25/2023
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Provider Practice Location Address
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Address Line | 150 SW 12TH AVE STE 491
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City | POMPANO BEACH
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State | FL
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Zip | 33069-3298
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Country | US
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Telephone | 888-207-3177
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Fax |
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Provider Business Mailing Address
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Address Line | 6278 NORTH FEDERAL HIGHWAY PMB 370
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City | FORT LAUDERDALE
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State | FL
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Zip | 33308-1916
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | MR. AUGUSTINE CROCCO
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Credential | LCSW
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Telephone | 267-744-4265
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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