Provider Demographics
NPI:1255701199
Name:BOCA RATON COUNSELING CENTER LLC
Entity type:Organization
Organization Name:BOCA RATON COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KEBRE
Authorized Official - Suffix:
Authorized Official - Credentials:MA; LMFT
Authorized Official - Phone:310-594-9974
Mailing Address - Street 1:17723 TIFFANY TRACE DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-1225
Mailing Address - Country:US
Mailing Address - Phone:310-594-9974
Mailing Address - Fax:
Practice Address - Street 1:17723 TIFFANY TRACE DR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-1225
Practice Address - Country:US
Practice Address - Phone:310-594-9974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3057106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty