=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659821718
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIORAL HEALTH MANAGEMENT SERVICES INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2016
-----------------------------------------------------
Last Update Date | 10/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2995 DREW ST 2ND FLOOR
-----------------------------------------------------
City | CLEARWATER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33759-3012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-281-9065
-----------------------------------------------------
Fax | 813-635-2613
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3440 W DR MLK BLVD STE 203
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33607-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-254-8055
-----------------------------------------------------
Fax | 813-443-8163
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP, PT FINANCIAL SERVICES
-----------------------------------------------------
Name | LYNDA GORKEN
-----------------------------------------------------
Credential | VP
-----------------------------------------------------
Telephone | 727-281-9202
-----------------------------------------------------
=====================================================
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 | FL
-----------------------------------------------------