MEDICARE: BEAUTIFUL MIND BEHAVIORAL SERVICES, CORP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1275013542
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEAUTIFUL MIND BEHAVIORAL SERVICES, CORP.

Provider Business Mailing Address
First Line	:	1137 BARTOW RD STE A
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-5828
Country	:	US
Telephone Number	:	863-313-0049
Fax Number	:	863-248-1970

Provider Business Practice Location Address
First Line	:	1137 BARTOW RD STE A
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33801-5828
Country	:	US
Telephone Number	:	863-313-0049
Fax Number	:	863-248-1970

Authorized Official
Title or Position	:	OWNER
Name	:	DEYSI FERNANDEZ
Credential	:
Telephone Number	:	863-313-0049

Provider Enumeration Date	:	08/16/2018
Last Update Date	:	08/16/2018

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