=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588381396
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEAUTIFUL MINDS TARGETED CASE MANAGEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2022
-----------------------------------------------------
Last Update Date | 10/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2860 SAINT AUGUSTINE DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-7140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-470-3630
-----------------------------------------------------
Fax | 407-270-5935
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2860 SAINT AUGUSTINE DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32825-7140
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-470-3630
-----------------------------------------------------
Fax | 407-270-5935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DAVENA SHABAZZ
-----------------------------------------------------
Credential | CBHCMS
-----------------------------------------------------
Telephone | 407-470-3630
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------