Provider Demographics
NPI:1770762593
Name:THE FAMILY MENTAL HEALTH PRACTICE
Entity type:Organization
Organization Name:THE FAMILY MENTAL HEALTH PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRIVATE PRACTICE
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:DEROCHE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:386-439-1403
Mailing Address - Street 1:701 N CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:FLAGLER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32136
Mailing Address - Country:US
Mailing Address - Phone:386-439-1403
Mailing Address - Fax:386-439-1403
Practice Address - Street 1:2760 SW 17TH ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471
Practice Address - Country:US
Practice Address - Phone:352-629-4113
Practice Address - Fax:386-439-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH0000050101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty