Provider Demographics
NPI:1114338464
Name:THE BRAIN TREATMENT CENTERS OF SOUTH FLORIDA
Entity Type:Organization
Organization Name:THE BRAIN TREATMENT CENTERS OF SOUTH FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CICETTI
Authorized Official - Suffix:
Authorized Official - Credentials:PSY, D
Authorized Official - Phone:844-469-2724
Mailing Address - Street 1:2290 10TH AVE N STE 201
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461-6609
Mailing Address - Country:US
Mailing Address - Phone:844-469-2724
Mailing Address - Fax:
Practice Address - Street 1:2290 10TH AVE N STE 201
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-6609
Practice Address - Country:US
Practice Address - Phone:844-469-2724
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7715103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAN583Medicare PIN