Healthcare Provider Details

I. General information

NPI: 1710715727
Provider Name (Legal Business Name): EASTERSEALS NORTHEAST CENTRAL FLORIDA, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W NEW YORK AVE
DELAND FL
32720-5239
US

IV. Provider business mailing address

1219 DUNN AVE
DAYTONA BEACH FL
32114-2405
US

V. Phone/Fax

Practice location:
  • Phone: 386-255-4568
  • Fax: 386-258-7677
Mailing address:
  • Phone: 386-255-4568
  • Fax: 386-258-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MICHELE WALLENS
Title or Position: ACCOUNTING MANAGER
Credential:
Phone: 386-255-4568