Basic Information
| Provider Information | |||||||||
| NPI: | 1659821718 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BEHAVIORAL HEALTH MANAGEMENT SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BAYCARE LIFE MANAGEMENT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3440 W DR MLK BLVD STE 203 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132548055 | ||||||||
| FaxNumber: | 8134438163 | ||||||||
| Practice Location | |||||||||
| Address1: | 2995 DREW ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819065 | ||||||||
| FaxNumber: | 8136352613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2016 | ||||||||
| LastUpdateDate: | 10/15/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP, PT FINANCIAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 7272819202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | VP | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | FL | MEDICAID |