Provider Demographics
NPI:1356956114
Name:CHRYSALIS COUNSELING CENTER LLC
Entity type:Organization
Organization Name:CHRYSALIS COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROCKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:386-310-7436
Mailing Address - Street 1:3930 S NOVA RD STE 303
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-9293
Mailing Address - Country:US
Mailing Address - Phone:386-310-7436
Mailing Address - Fax:386-259-6112
Practice Address - Street 1:3930 S NOVA RD STE 303
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9293
Practice Address - Country:US
Practice Address - Phone:386-310-7436
Practice Address - Fax:386-259-6112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-09
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108142800Medicaid
FL020114000Medicaid