Provider Demographics
NPI:1619119690
Name:CATHRYN E VAN BRACKLE PSYD LLC
Entity Type:Organization
Organization Name:CATHRYN E VAN BRACKLE PSYD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:CATHRYN
Authorized Official - Middle Name:E
Authorized Official - Last Name:VAN BRACKLE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:305-331-2553
Mailing Address - Street 1:600 JIMMY ANN DR
Mailing Address - Street 2:1918
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-7407
Mailing Address - Country:US
Mailing Address - Phone:305-331-2553
Mailing Address - Fax:
Practice Address - Street 1:600 JIMMY ANN DR
Practice Address - Street 2:1918
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-7407
Practice Address - Country:US
Practice Address - Phone:305-331-2553
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY7396103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty