Basic Information
| Provider Information | |||||||||
| NPI: | 1316142334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CFSATC, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CENTRAL FLORIDA TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 N COCOA BLVD | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329227749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216314578 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7 N COCOA BLVD | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329227749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216314578 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 05/19/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KNEESSY | ||||||||
| AuthorizedOfficialFirstName: | DAVE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3219519750 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MS, LMHC, MCAP | ||||||||
| NPICertificationDate: | 05/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 0705AD119401 | FL | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 075363700 | 05 | FL | MEDICAID |