Provider Demographics
NPI:1275809964
Name:DELETE ORGANIZATION NPI
Entity Type:Organization
Organization Name:DELETE ORGANIZATION NPI
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC, CAP
Authorized Official - Phone:772-873-8811
Mailing Address - Street 1:1062 SW PAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-3472
Mailing Address - Country:US
Mailing Address - Phone:772-249-5878
Mailing Address - Fax:
Practice Address - Street 1:1551 FORUM PL
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-2319
Practice Address - Country:US
Practice Address - Phone:561-712-8821
Practice Address - Fax:561-217-8070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health