Provider Demographics
NPI:1144004912
Name:JERRY, TONY LEVON (LCDC)
Entity type:Individual
Prefix:
First Name:TONY
Middle Name:LEVON
Last Name:JERRY
Suffix:
Gender:M
Credentials:LCDC
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:NONE
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCDC
Mailing Address - Street 1:2368 CENTER STONE LN
Mailing Address - Street 2:
Mailing Address - City:RIVIERA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33404-1828
Mailing Address - Country:US
Mailing Address - Phone:713-859-7814
Mailing Address - Fax:
Practice Address - Street 1:2368 CENTER STONE LN
Practice Address - Street 2:
Practice Address - City:RIVIERA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33404-1828
Practice Address - Country:US
Practice Address - Phone:713-859-7814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14828101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)