Healthcare Provider Details

I. General information

NPI: 1861991481
Provider Name (Legal Business Name): VIDA BEHAVIORAL HEALTH ASSOCIATES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3307 NORTHLAKE BLVD STE B104
PALM BEACH GARDENS FL
33403-1703
US

IV. Provider business mailing address

3307 NORTHLAKE BLVD STE B104
PALM BEACH GARDENS FL
33403-1703
US

V. Phone/Fax

Practice location:
  • Phone: 561-618-5072
  • Fax:
Mailing address:
  • Phone: 401-862-7292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH13781
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSSI PEREZ
Title or Position: LICENSED MENTAL HEALTH COUNSELOR
Credential: LMHC
Phone: 401-862-7292