Provider Demographics
NPI:1033587795
Name:INDIVIDUAL PROVIDER
Entity Type:Organization
Organization Name:INDIVIDUAL PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASTER'S LEVEL CONTRACT CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GARRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-697-8932
Mailing Address - Street 1:650 PALERMO VISTA CT
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-3419
Mailing Address - Country:US
Mailing Address - Phone:317-697-8932
Mailing Address - Fax:
Practice Address - Street 1:650 PALERMO VISTA CT
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-3419
Practice Address - Country:US
Practice Address - Phone:317-697-8932
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW10093251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health