Healthcare Provider Details

I. General information

NPI: 1780286393
Provider Name (Legal Business Name): POINCIANA BEHAVIORAL HEALTH CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2068 E OSCEOLA PKWY
KISSIMMEE FL
34743-8602
US

IV. Provider business mailing address

PO BOX 584792
KISSIMMEE FL
34758
US

V. Phone/Fax

Practice location:
  • Phone: 407-483-3939
  • Fax: 407-449-4321
Mailing address:
  • Phone: 407-483-3939
  • Fax: 407-449-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EULADIA MERCADO
Title or Position: OWNER
Credential: BSN/RN
Phone: 407-572-8862