Healthcare Provider Details

I. General information

NPI: 1497354690
Provider Name (Legal Business Name): FL PSYCHIATRIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2020
Last Update Date: 07/27/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SE OCEAN BLVD
STUART FL
34994-2214
US

IV. Provider business mailing address

PO BOX 3743
YOUNGSTOWN OH
44513-3743
US

V. Phone/Fax

Practice location:
  • Phone: 772-400-2875
  • Fax: 772-400-2876
Mailing address:
  • Phone: 330-965-9999
  • Fax: 330-757-0000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
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: MUHANNAD KASSAWAT
Title or Position: OWNER
Credential: MD
Phone: 330-965-9999