Basic Information
Provider Information | |||||||||
NPI: | 1215462288 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARADISE BEHAVIORAL HEALTH, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25097 OLYMPIA AVE STE 205 | ||||||||
Address2: |   | ||||||||
City: | PUNTA GORDA | ||||||||
State: | FL | ||||||||
PostalCode: | 339503912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9413478341 | ||||||||
FaxNumber: | 9413477702 | ||||||||
Practice Location | |||||||||
Address1: | 25097 OLYMPIA AVE STE 205 | ||||||||
Address2: |   | ||||||||
City: | PUNTA GORDA | ||||||||
State: | FL | ||||||||
PostalCode: | 339503912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9413478341 | ||||||||
FaxNumber: | 9413477702 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/26/2017 | ||||||||
LastUpdateDate: | 11/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAMAYO | ||||||||
AuthorizedOfficialFirstName: | MIZYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9413478341 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 11/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | ME114111 | FL | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 103283300 | 05 | FL |   | MEDICAID |