Healthcare Provider Details

I. General information

NPI: 1053030643
Provider Name (Legal Business Name): EVERNORTH BEHAVIORAL CARE GROUP OF FLORIDA, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2022
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 TECHNOLOGY PARK
LAKE MARY FL
32746-6211
US

IV. Provider business mailing address

625 MARKET ST FL 15
SAN FRANCISCO CA
94105-3316
US

V. Phone/Fax

Practice location:
  • Phone: 877-501-7991
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH NELSON
Title or Position: LEGAL COUNSEL
Credential:
Phone: 843-540-7108