Provider Demographics
NPI:1154650620
Name:MISTY MOUNTAIN FAMILY ENRICHMENT CENTER
Entity Type:Organization
Organization Name:MISTY MOUNTAIN FAMILY ENRICHMENT CENTER
Other - Org Name:SOUTHWEST FLORIDA CHRISTIAN COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:HASEK
Authorized Official - Suffix:
Authorized Official - Credentials:MA/MFT LPC, LMHC
Authorized Official - Phone:239-301-4464
Mailing Address - Street 1:24840 BURNT PINE DR
Mailing Address - Street 2:SUITES 1 & 2
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34134-2999
Mailing Address - Country:US
Mailing Address - Phone:239-301-4464
Mailing Address - Fax:503-684-6289
Practice Address - Street 1:24840 BURNT PINE DR
Practice Address - Street 2:SUITES 1 & 2
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34134-2999
Practice Address - Country:US
Practice Address - Phone:239-301-4464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-13
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 13637251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health