Provider Demographics
NPI:1932325883
Name:THE CHRYSALIS CENTER
Entity Type:Organization
Organization Name:THE CHRYSALIS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:TARA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KELLOGG
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:954-587-1008
Mailing Address - Street 1:3521 W BROWARD BLVD
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1048
Mailing Address - Country:US
Mailing Address - Phone:954-587-1008
Mailing Address - Fax:954-587-0080
Practice Address - Street 1:3521 W BROWARD BLVD
Practice Address - Street 2:3RD FLOOR
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-1048
Practice Address - Country:US
Practice Address - Phone:954-587-1008
Practice Address - Fax:954-587-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT2003251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health