Provider Demographics
NPI:1699033381
Name:SPANISH RIVER CHURCH
Entity Type:Organization
Organization Name:SPANISH RIVER CHURCH
Other - Org Name:SPANISH RIVER COUNSELING CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:561-241-9014
Mailing Address - Street 1:2400 YAMATO RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33431-8403
Mailing Address - Country:US
Mailing Address - Phone:561-241-9014
Mailing Address - Fax:561-994-2263
Practice Address - Street 1:2400 YAMATO RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-8403
Practice Address - Country:US
Practice Address - Phone:561-241-9014
Practice Address - Fax:561-994-2263
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPANISH RIVER CHURCH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-01
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6752103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty