Provider Demographics
NPI:1629128186
Name:BREVARD PSYCHIATRY & PSYCHOLOGY INC
Entity Type:Organization
Organization Name:BREVARD PSYCHIATRY & PSYCHOLOGY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:RAFAEL
Authorized Official - Last Name:GONZALEZ-SOLTERO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:321-751-1925
Mailing Address - Street 1:6767 N WICKHAM ROAD
Mailing Address - Street 2:SUITE 306
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940
Mailing Address - Country:US
Mailing Address - Phone:321-751-1925
Mailing Address - Fax:321-751-9261
Practice Address - Street 1:6767 N WICKHAM ROAD
Practice Address - Street 2:SUITE 306
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940
Practice Address - Country:US
Practice Address - Phone:321-751-1925
Practice Address - Fax:321-751-9261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL34626Medicare PIN