Basic Information
| Provider Information | |||||||||
| NPI: | 1598881153 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS FLORIDA, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 CROSBY WAY | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076297881 | ||||||||
| FaxNumber: | 4072947546 | ||||||||
| Practice Location | |||||||||
| Address1: | 2010 CROSBY WAY | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327924119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076297881 | ||||||||
| FaxNumber: | 4076294754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | RIKESHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4076297881 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EASTER SEALS FLORIDA, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 261QA0600X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Day Care |
ID Information
| ID | Type | State | Issuer | Description | 677108400 | 05 | FL | MEDICAID | 110726200 | 05 | FL | MEDICAID | 683166400 | 05 | FL | MEDICAID |