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General NPI Number Information
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NPI Number | 1942952213
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Entity Type | Organization
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Legal Business Name | MANGROVE THERAPY GROUP LLC
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Dates
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Enumeration Date | 01/19/2022
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Last Update Date | 01/19/2022
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Provider Practice Location Address
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Address Line | 401 LINTON BLVD STE 200A
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City | DELRAY BEACH
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State | FL
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Zip | 33444-8157
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Country | US
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Telephone | 564-404-0165
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Fax | 561-847-3299
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Provider Business Mailing Address
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Address Line | 401 LINTON BLVD STE 200A
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City | DELRAY BEACH
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State | FL
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Zip | 33444-8157
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Country | US
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Telephone | 564-404-0165
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Fax | 561-847-3299
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Authorized Official
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Title or Position | OWNER/PRACTITIONER
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Name | BRIAN GONG
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Credential | LMHC
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Telephone | 561-404-0165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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