1093025702 NPI number — PSYCHAMERICA BEHAVIORAL SERVICES LLC

Table of content: (NPI 1093025702)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093025702 NPI number — PSYCHAMERICA BEHAVIORAL SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PSYCHAMERICA BEHAVIORAL SERVICES LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
BIG BEAR BEHAVIORAL HEALTH
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093025702
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/05/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 784719
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER GARDEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34778-4719
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-840-2528
Provider Business Mailing Address Fax Number:
407-540-9552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7065 WESTPOINTE BLVD STE 308
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32835-8758
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-840-2528
Provider Business Practice Location Address Fax Number:
407-540-9552
Provider Enumeration Date:
10/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MAGNASCO
Authorized Official First Name:
MAX
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
800-840-2528

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103TP2701X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: L10000019130 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0801X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 002803500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 014778600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0045890-00 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 014148500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 002803500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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