=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194045641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL FLORIDA MENTAL HEALTH ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2010
-----------------------------------------------------
Last Update Date | 11/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 125 W PLYMOUTH AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-2745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-736-9165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 125 W PLYMOUTH AVE
-----------------------------------------------------
City | DELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32720-2745
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-736-9165
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. TRAVIS M MCBRIDE
-----------------------------------------------------
Credential | MA, LMHC
-----------------------------------------------------
Telephone | 386-747-6848
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------