Provider Demographics
NPI:1720101736
Name:BRILLIANT MINDS
Entity type:Organization
Organization Name:BRILLIANT MINDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINCAL DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BALLONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-837-1200
Mailing Address - Street 1:36468 EMERALD COAST PKWY
Mailing Address - Street 2:SUITE 2101
Mailing Address - City:DESTIN
Mailing Address - State:FL
Mailing Address - Zip Code:32541
Mailing Address - Country:US
Mailing Address - Phone:850-837-1200
Mailing Address - Fax:850-269-2341
Practice Address - Street 1:36468 EMERALD COAST PKWY
Practice Address - Street 2:SUITE 2101
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-4799
Practice Address - Country:US
Practice Address - Phone:850-837-1200
Practice Address - Fax:850-269-2341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL90051001284101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty