Healthcare Provider Details

I. General information

NPI: 1669236055
Provider Name (Legal Business Name): PROFESSIONAL BEHAVIORAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2024
Last Update Date: 02/07/2024
Certification Date: 02/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 LEXINGTON GREEN LN
SANFORD FL
32771-1025
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 TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: ANEL FUENTES FLORES
Title or Position: PRACTICE DIRECTOR
Credential: TCM
Phone: 402-222-8145