Basic Information
| Provider Information | |||||||||
| NPI: | 1285662841 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HOMESTEAD BEHAVIORAL CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 654 NE 9TH PL | ||||||||
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| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330304934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052483488 | ||||||||
| FaxNumber: | 3052486558 | ||||||||
| Practice Location | |||||||||
| Address1: | 654 NE 9TH PL | ||||||||
| Address2: | |||||||||
| City: | HOMESTEAD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330304934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052483488 | ||||||||
| FaxNumber: | 3052486558 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 09/29/2021 | ||||||||
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| AuthorizedOfficialLastName: | LOPEZ | ||||||||
| AuthorizedOfficialFirstName: | AIDELYN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3052483488 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | HCC 4035 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 251B00000X | N | Agencies | Case Management | 261QA0600X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care | 261QM0801X | HCC4181 | FL | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 251S00000X | HCC4181 | FL | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 260257100 | 05 | FL | MEDICAID | 678856400 | 05 | FL | MEDICAID | 000350100 | 05 | FL | MEDICAID | 002005600 | 05 | FL | MEDICAID | 018520000 | 05 | FL | MEDICAID |