Provider Demographics
NPI:1487043410
Name:SUNDANCE RANCH CHRISTIAN CHURCH
Entity Type:Organization
Organization Name:SUNDANCE RANCH CHRISTIAN CHURCH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WHARTON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:321-305-5946
Mailing Address - Street 1:1900 PINE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-6517
Mailing Address - Country:US
Mailing Address - Phone:215-559-1184
Mailing Address - Fax:
Practice Address - Street 1:390 S COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4847
Practice Address - Country:US
Practice Address - Phone:321-305-5946
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-14
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL204811419101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty