Basic Information
| Provider Information | |||||||||
| NPI: | 1306108253 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAYCARE BEHAVIORAL HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DORIS COOK - CASE MGMT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 DREW ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337593012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7272819390 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 14527 7TH ST | ||||||||
| Address2: | |||||||||
| City: | DADE CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335233102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275211474 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2012 | ||||||||
| LastUpdateDate: | 02/12/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GORKEN | ||||||||
| AuthorizedOfficialFirstName: | LYNDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7272819390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 060297325 | 05 | FL | MEDICAID |