Basic Information
| Provider Information | |||||||||
| NPI: | 1982922829 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IMPACT BEHAVIORAL HEALTH LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1965 CAPITAL CIR NE STE 200 | ||||||||
| Address2: | |||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323088402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506562006 | ||||||||
| FaxNumber: | 8506562820 | ||||||||
| Practice Location | |||||||||
| Address1: | 1965 CAPITAL CIR NE | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | TALLAHASSEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 323088401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506714600 | ||||||||
| FaxNumber: | 8508782863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2010 | ||||||||
| LastUpdateDate: | 12/01/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MIGNON | ||||||||
| AuthorizedOfficialFirstName: | YVETTE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8506562006 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 101Y00000X | 8447 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YM0800X | 8447 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 104100000X | 6702 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6702 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 324500000X | FL | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 600680931 | 01 | FL | MAGELLAN | OTHER | 2386 | 01 | GA | LICENSED PROFESSIONAL COUNSELOR | OTHER | 648299630A | 05 | GA | MEDICAID | 003214900 | 05 | FL | MEDICAID | 8447 | 01 | FL | LICENSED MENTAL HEALTH COUNSELOR | OTHER |