1851060495 NPI number — BYBROOK BEHAVIORAL HEALTH SERVICES, PA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851060495 NPI number — BYBROOK BEHAVIORAL HEALTH SERVICES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BYBROOK BEHAVIORAL HEALTH SERVICES, PA
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:
Provider Other Organization Name Type Code:
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:
1851060495
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3065 DANIELS RD # 1077
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:
34787-7002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-661-1677
Provider Business Mailing Address Fax Number:
407-278-4062

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3065 DANIELS RD # 1077
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER GARDEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34787-7002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-661-1677
Provider Business Practice Location Address Fax Number:
407-278-4062
Provider Enumeration Date:
09/08/2021

Additional Information

Authorized Official

Authorized Official Last Name:
FORGIE
Authorized Official First Name:
ROAN
Authorized Official Middle Name:
EMANUEL
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
646-591-4970

Provider Taxonomy Codes

  • Taxonomy code: 363LP0808X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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