1881216877 NPI number — PEDIATRIC BEHAVIORAL HEALTH ASSOCIATES, INC.

Table of content: (NPI 1881216877)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881216877 NPI number — PEDIATRIC BEHAVIORAL HEALTH ASSOCIATES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC BEHAVIORAL HEALTH ASSOCIATES, INC.
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:
1881216877
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2735 SE 140TH PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUMMERFIELD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34491-2877
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-706-1004
Provider Business Mailing Address Fax Number:
561-892-0268

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5818 SE AGNEW RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVIEW
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34420-4020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-706-1004
Provider Business Practice Location Address Fax Number:
561-892-0268
Provider Enumeration Date:
05/12/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WOLLER
Authorized Official First Name:
NICOLE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
561-706-1004

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 102843600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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