Provider Demographics
NPI:1780931469
Name:VISIONARY VANGUARD GROUP
Entity type:Organization
Organization Name:VISIONARY VANGUARD GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LMHC, NCC, BCAB
Authorized Official - Phone:407-497-0327
Mailing Address - Street 1:976 LAKE BALDWIN LN
Mailing Address - Street 2:SUITE 203
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32814-6687
Mailing Address - Country:US
Mailing Address - Phone:407-497-0327
Mailing Address - Fax:888-587-1421
Practice Address - Street 1:1200 OAKLEY SEAVER DR
Practice Address - Street 2:SUITE 203
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-1958
Practice Address - Country:US
Practice Address - Phone:407-314-5373
Practice Address - Fax:888-587-1421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-13
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH6078101YM0800X
NCC #54428101YM0800X
NCC #48936101YM0800X
FL0000077103K00000X
FLMH6575101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty