Basic Information
Provider Information | |||||||||
NPI: | 1659326130 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEHAVIORAL HEALTH MANAGEMENT SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BAYCARE LIFE MANAGEMENT | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 403974 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303843974 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138523272 | ||||||||
FaxNumber: | 8136352613 | ||||||||
Practice Location | |||||||||
Address1: | 2727 W DR MARTIN LUTHER KING JR BLVD | ||||||||
Address2: | SUITE 640 | ||||||||
City: | TAMPA | ||||||||
State: | FL | ||||||||
PostalCode: | 336076383 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8138727582 | ||||||||
FaxNumber: | 8136352613 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2006 | ||||||||
LastUpdateDate: | 04/16/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GORKEN | ||||||||
AuthorizedOfficialFirstName: | LYNDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP/FINANCIAL SVCS | ||||||||
AuthorizedOfficialTelephone: | 8138523304 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 267725300 | 05 | FL |   | MEDICAID |