Basic Information
| Provider Information | |||||||||
| NPI: | 1801883160 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHAUTAUQUA OFFICES OF PSYCHOTHERAPY AND EVALUATION, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | C.O.P.E. CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3686 US HIGHWAY 331 S | ||||||||
| Address2: | |||||||||
| City: | DEFUNIAK SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324358463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508928045 | ||||||||
| FaxNumber: | 8508928039 | ||||||||
| Practice Location | |||||||||
| Address1: | 3686 US HIGHWAY 331 S | ||||||||
| Address2: | |||||||||
| City: | DEFUNIAK SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324358463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508928045 | ||||||||
| FaxNumber: | 8508928039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2005 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GILLIS | ||||||||
| AuthorizedOfficialFirstName: | RACHEL | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8508928045 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LCSW BCD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | 0166AD9145-01 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 060369400 | 05 | FL | MEDICAID | 77467 | 01 | FL | BC/BS | OTHER |