Provider Demographics
NPI:1942952213
Name:MANGROVE THERAPY GROUP LLC
Entity type:Organization
Organization Name:MANGROVE THERAPY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GONG
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:561-404-0165
Mailing Address - Street 1:401 LINTON BLVD STE 200A
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33444-8157
Mailing Address - Country:US
Mailing Address - Phone:564-404-0165
Mailing Address - Fax:561-847-3299
Practice Address - Street 1:401 LINTON BLVD STE 200A
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33444-8157
Practice Address - Country:US
Practice Address - Phone:564-404-0165
Practice Address - Fax:561-847-3299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty