Provider Demographics
NPI:1104177948
Name:ENLOE BRUCE BILLINGSLEY LCSW PA
Entity Type:Organization
Organization Name:ENLOE BRUCE BILLINGSLEY LCSW PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:ENLOE
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:BILLINGSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:813-654-8916
Mailing Address - Street 1:1210 MILLENNIUM PARKWAY
Mailing Address - Street 2:SUITE 1030
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-4858
Mailing Address - Country:US
Mailing Address - Phone:813-654-8916
Mailing Address - Fax:813-654-6952
Practice Address - Street 1:1210 MILLENNIUM PKWY
Practice Address - Street 2:SUITE 1030
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4896
Practice Address - Country:US
Practice Address - Phone:813-654-8916
Practice Address - Fax:813-654-6952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW0000194101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ1594OtherBC/BS