Provider Demographics
NPI:1659806313
Name:COUNSELING CENTER OF BREVARD, LLC
Entity Type:Organization
Organization Name:COUNSELING CENTER OF BREVARD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LMHC
Authorized Official - Prefix:MRS
Authorized Official - First Name:KARIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PAINTER
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:321-543-1185
Mailing Address - Street 1:1413 S. PATRICK DR.
Mailing Address - Street 2:SUITE 1
Mailing Address - City:INDIAN HARBOUR BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32937
Mailing Address - Country:US
Mailing Address - Phone:321-432-9282
Mailing Address - Fax:321-777-5964
Practice Address - Street 1:1413 S PATRICK DR
Practice Address - Street 2:SUITE 1
Practice Address - City:INDIAN HARBOUR BEACH
Practice Address - State:FL
Practice Address - Zip Code:32937-4373
Practice Address - Country:US
Practice Address - Phone:321-432-9282
Practice Address - Fax:321-777-5964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-01
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 13192305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018561500Medicaid