Provider Demographics
NPI:1013059401
Name:PROFESSIONAL TRAINING ASSOCIATION CORPORATION
Entity Type:Organization
Organization Name:PROFESSIONAL TRAINING ASSOCIATION CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:E
Authorized Official - Last Name:WALLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-494-0866
Mailing Address - Street 1:321 NORTHLAKE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:NORTH PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33408-5422
Mailing Address - Country:US
Mailing Address - Phone:561-494-0866
Mailing Address - Fax:561-494-0984
Practice Address - Street 1:321 NORTHLAKE BLVD
Practice Address - Street 2:#102
Practice Address - City:NORTH PALM BAECH
Practice Address - State:FL
Practice Address - Zip Code:33408
Practice Address - Country:US
Practice Address - Phone:561-494-0866
Practice Address - Fax:561-494-0984
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101YM0800X
FL1550AD384701261QM0801X
FL0950AD384702261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)