1790759751 NPI number — MRS. RACHEL LONG BRINK L.C.S.W., B.C.D.

Table of content: MRS. RACHEL LONG BRINK L.C.S.W., B.C.D. (NPI 1790759751)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790759751 NPI number — MRS. RACHEL LONG BRINK L.C.S.W., B.C.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRINK
Provider First Name:
RACHEL
Provider Middle Name:
LONG
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.C.S.W., B.C.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLQUITT
Provider Other First Name:
RACHEL
Provider Other Middle Name:
LONG
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
L.C.S.W.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790759751
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3743 EAGLEFLIGHT LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAND O LAKES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34639-4080
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-995-2530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14517 BRUCE B DOWNS BLVD
Provider Second Line Business Practice Location Address:
SUITE #201
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33613-2755
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-228-2761
Provider Business Practice Location Address Fax Number:
813-225-7048
Provider Enumeration Date:
02/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  SW 5706 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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