Healthcare Provider Details

I. General information

NPI: 1962989806
Provider Name (Legal Business Name): THRIVE BEHAVIORAL SCIENCES TAMPA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5510 N HESPERIDES ST
TAMPA FL
33614-5414
US

IV. Provider business mailing address

5510 N HESPERIDES ST
TAMPA FL
33614-5414
US

V. Phone/Fax

Practice location:
  • Phone: 813-467-6111
  • Fax: 813-467-6013
Mailing address:
  • Phone: 813-277-4571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: JOLENE DE LA GARDELLE
Title or Position: VP - OPERATIONS
Credential:
Phone: 813-277-4571