Provider Demographics
NPI:1518351824
Name:BREVARD PSYCHOLOGICAL ASSOCIATES, INC
Entity Type:Organization
Organization Name:BREVARD PSYCHOLOGICAL ASSOCIATES, INC
Other - Org Name:TIMOTHY C. SHORT, PSY. D
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHORT, PSY. D
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGIST
Authorized Official - Phone:321-724-2444
Mailing Address - Street 1:1611 SOUTH APOLLO BLVD.
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901
Mailing Address - Country:US
Mailing Address - Phone:321-724-2444
Mailing Address - Fax:321-952-4131
Practice Address - Street 1:1611 S APOLLO BLVD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-4407
Practice Address - Country:US
Practice Address - Phone:321-724-2444
Practice Address - Fax:321-952-4131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4790103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL611051700OtherWORKERS COMPENSATION
FL59348OtherBLUE CROSS BLUE SHIELT OF FLORIDA
FL59348OtherBLUE CROSS BLUE SHIELT OF FLORIDA