Healthcare Provider Details

I. General information

NPI: 1205295094
Provider Name (Legal Business Name): DRA BEHAVIORAL HEALTH CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2016
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6107 PALM DR
FORT PIERCE FL
34982-7577
US

IV. Provider business mailing address

6107 PALM DR
FORT PIERCE FL
34982-7577
US

V. Phone/Fax

Practice location:
  • Phone: 954-394-2835
  • Fax:
Mailing address:
  • Phone: 954-394-2835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberSW2625
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number59748
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberSW 2625
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number59748
License Number StateFL

VIII. Authorized Official

Name: DAISY RAVELO
Title or Position: PRESIDENT
Credential: INTERN MFT
Phone: 954-394-2835