Healthcare Provider Details

I. General information

NPI: 1689164790
Provider Name (Legal Business Name): SOUTHEASTERN BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 12/28/2019
Certification Date: 12/28/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 THOMASVILLE RD STE 102
TALLAHASSEE FL
32308-7912
US

IV. Provider business mailing address

3303 THOMASVILLE RD STE 102
TALLAHASSEE FL
32308-7912
US

V. Phone/Fax

Practice location:
  • Phone: 850-296-3665
  • Fax: 850-296-3665
Mailing address:
  • Phone: 850-296-3665
  • Fax: 850-296-3665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY10048
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberSS1033
License Number StateFL

VIII. Authorized Official

Name: DR. ANGELA CANTO
Title or Position: OWNER/AUTHORIZED REPRESENTATIVE
Credential: PH.D.
Phone: 850-296-3665