Basic Information
| Provider Information | |||||||||
| NPI: | 1346224011 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENTAL HEALTH CARE, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | GRACEPOINT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5707 N. 22ND STREET | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336104350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132398069 | ||||||||
| FaxNumber: | 8132317324 | ||||||||
| Practice Location | |||||||||
| Address1: | 5707 N. 22ND STREET | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336104350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132398069 | ||||||||
| FaxNumber: | 8132317324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2005 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TYSON | ||||||||
| AuthorizedOfficialFirstName: | ROAYA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO EFFECTIVE 9/1/2022 | ||||||||
| AuthorizedOfficialTelephone: | 8132398069 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MENTAL HEALTH CARE, INC GRACEPOI | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 0827999 | 05 | FL | MEDICAID | 227811 | 05 | FL | MEDICAID | 060272800 | 05 | FL | MEDICAID | 21336 | 05 | FL | MEDICAID | 060272801 | 05 | FL | MEDICAID | 060272815 | 05 | FL | MEDICAID |