=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154178481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TMS AT THE LAKE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2024
-----------------------------------------------------
Last Update Date | 05/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 168 NW BLACKBEAR WAY
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-387-2671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 168 NW BLACKBEAR WAY
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-387-2671
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DEVAN SCHANDING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-387-2671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------