Healthcare Provider Details

I. General information

NPI: 1841735750
Provider Name (Legal Business Name): CROSSROADS ADDICTION SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2016
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 SW SAINT LUCIE WEST BLVD STE 106
PORT ST LUCIE FL
34986-1709
US

IV. Provider business mailing address

1420 SW SAINT LUCIE WEST BLVD
PORT ST LUCIE FL
34986-1709
US

V. Phone/Fax

Practice location:
  • Phone: 772-242-5408
  • Fax:
Mailing address:
  • Phone: 772-242-5408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. THERESA A BIEMER
Title or Position: PRESIDENT
Credential: PA-C
Phone: 772-242-5408