Basic Information
| Provider Information | |||||||||
| NPI: | 1033482955 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THOMAS B. UNSWORTH P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 451 SW BETHANY DR | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349861964 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615412005 | ||||||||
| FaxNumber: | 7728792077 | ||||||||
| Practice Location | |||||||||
| Address1: | 6269 NW GISELA ST | ||||||||
| Address2: | |||||||||
| City: | PORT SAINT LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349863866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615412005 | ||||||||
| FaxNumber: | 7728792077 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2012 | ||||||||
| LastUpdateDate: | 02/23/2012 | ||||||||
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| AuthorizedOfficialLastName: | UNSWORTH | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | BRANDON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5615412005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THOMAS B. UNSWORTH P.A. | ||||||||
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| AuthorizedOfficialCredential: | LMHC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH4732 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.