Provider Demographics
NPI:1932389483
Name:PREVENT OF BREVARD, INC.
Entity type:Organization
Organization Name:PREVENT OF BREVARD, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECOTR
Authorized Official - Prefix:MS
Authorized Official - First Name:RAHILA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASHIR
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:407-207-7544
Mailing Address - Street 1:1948 PINEAPPLE AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-7609
Mailing Address - Country:US
Mailing Address - Phone:321-259-7262
Mailing Address - Fax:
Practice Address - Street 1:2115 BABCOCK ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901
Practice Address - Country:US
Practice Address - Phone:321-729-0779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PREVENT OF BREVARD, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-13
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1538369630251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health