Healthcare Provider Details

I. General information

NPI: 1679562797
Provider Name (Legal Business Name): PROFESSIONAL PSYCHIATRIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 02/04/2026
Certification Date: 02/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5449 S SEMORAN BLVD STE 20
ORLANDO FL
32822-1778
US

IV. Provider business mailing address

8614 BRACKENWOOD DR
ORLANDO FL
32829-8628
US

V. Phone/Fax

Practice location:
  • Phone: 407-734-1273
  • Fax:
Mailing address:
  • Phone: 787-645-7302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number6722
License Number StatePR
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateFL

VIII. Authorized Official

Name: ELBA FLORES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 407-734-1273