Provider Demographics
NPI:1689455149
Name:505 FAMILY THERAPY
Entity Type:Organization
Organization Name:505 FAMILY THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNALYSE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCERO
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:505-261-0923
Mailing Address - Street 1:1758 SIOUX TRL
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-9257
Mailing Address - Country:US
Mailing Address - Phone:505-234-6262
Mailing Address - Fax:
Practice Address - Street 1:1758 SIOUX TRL
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32563-9257
Practice Address - Country:US
Practice Address - Phone:505-234-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty