=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306120456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FLORIDA PSYCHIATRY ASSOCIATES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2011
-----------------------------------------------------
Last Update Date | 02/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 260 NW PEACOCK BLVD STE 102
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-2349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-878-7216
-----------------------------------------------------
Fax | 772-878-7218
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 260 NW PEACOCK BLVD STE 102
-----------------------------------------------------
City | PORT ST LUCIE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34986-2349
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-878-7216
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOANNA VANVLEET
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 772-878-7216
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------