Healthcare Provider Details

I. General information

NPI: 1306363783
Provider Name (Legal Business Name): OPTIMUM POTENTIAL COMMUNITY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BROADWAY STE 306
KISSIMMEE FL
34741-5706
US

IV. Provider business mailing address

120 BROADWAY STE 306
KISSIMMEE FL
34741-5706
US

V. Phone/Fax

Practice location:
  • Phone: 407-201-6577
  • Fax: 407-350-3425
Mailing address:
  • Phone: 407-201-6577
  • Fax: 407-350-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name: LUCILLE THOMAS
Title or Position: CEO
Credential: MS
Phone: 321-333-9197