Provider Demographics
NPI:1821343146
Name:DELRAY BEACH INTENSIVE OUTPATIENT PROGRAM LLC
Entity Type:Organization
Organization Name:DELRAY BEACH INTENSIVE OUTPATIENT PROGRAM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:SERGIO
Authorized Official - Last Name:MCCORMICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW, CAP
Authorized Official - Phone:561-894-6010
Mailing Address - Street 1:301 W ATLANTIC AVE
Mailing Address - Street 2:SUITE 0-5
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444-3687
Mailing Address - Country:US
Mailing Address - Phone:561-894-6010
Mailing Address - Fax:305-647-0680
Practice Address - Street 1:301 W ATLANTIC AVE
Practice Address - Street 2:SUITE 0-5
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33444-3687
Practice Address - Country:US
Practice Address - Phone:561-894-6010
Practice Address - Fax:305-647-0680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-24
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW35461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1134Medicare UPIN