Provider Demographics
NPI:1689334724
Name:PSYCHOTHERAPY CENTER OF INDIAN RIVER LLC
Entity Type:Organization
Organization Name:PSYCHOTHERAPY CENTER OF INDIAN RIVER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, MCAP
Authorized Official - Phone:772-584-2501
Mailing Address - Street 1:1717 20TH ST STE 102
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-0619
Mailing Address - Country:US
Mailing Address - Phone:772-584-2501
Mailing Address - Fax:
Practice Address - Street 1:1717 20TH ST STE 102
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-0619
Practice Address - Country:US
Practice Address - Phone:772-584-2501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-29
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty