Healthcare Provider Details

I. General information

NPI: 1902802002
Provider Name (Legal Business Name): LIFESTREAM BEHAVIORAL CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2005
Last Update Date: 07/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 TALLEY RD
LEESBURG FL
34748-3426
US

IV. Provider business mailing address

PO BOX 491000
LEESBURG FL
34749-1000
US

V. Phone/Fax

Practice location:
  • Phone: 352-315-7800
  • Fax: 352-315-6595
Mailing address:
  • Phone: 352-315-7500
  • Fax: 352-360-6595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code283Q00000X
TaxonomyPsychiatric Hospital
License Number4075
License Number StateFL

VIII. Authorized Official

Name: MS. CAROL E DOZIER
Title or Position: CFO
Credential: CPA
Phone: 352-315-7532