Basic Information
| Provider Information | |||||||||
| NPI: | 1912247396 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FATHER FLANAGAN'S BOYS TOWN FLORIDA, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1655 PALM BEACH LAKES BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616126000 | ||||||||
| FaxNumber: | 5616126097 | ||||||||
| Practice Location | |||||||||
| Address1: | 1655 PALM BEACH LAKES BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | WEST PALM BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334012203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5616126000 | ||||||||
| FaxNumber: | 5616126097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2013 | ||||||||
| LastUpdateDate: | 04/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | HEMINGS | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER OF A/R | ||||||||
| AuthorizedOfficialTelephone: | 5616126049 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | PY6149 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 011708800 | 05 | FL | MEDICAID |