MEDICARE: GIRLS EMPOWERED MENTALLY FOR SUCCESS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency		FL

General Provider Information

NPI Number	:	1043792765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GIRLS EMPOWERED MENTALLY FOR SUCCESS

Provider Business Mailing Address
First Line	:	PO BOX 292814
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33687-2814
Country	:	US
Telephone Number	:	813-300-2891
Fax Number	:

Provider Business Practice Location Address
First Line	:	5001 N NEBRASKA AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33603-2304
Country	:	US
Telephone Number	:	813-300-2891
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MS. CRYSTAL BAILES
Credential	:	MA
Telephone Number	:	813-495-5730

Provider Enumeration Date	:	08/29/2018
Last Update Date	:	08/29/2018

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