MEDICARE: DRA BEHAVIORAL HEALTH CORP

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	252Y00000X	Early Intervention Provider Agency	SW 2625	FL
2	251V00000X	Voluntary or Charitable Agency	59748	FL
3	305S00000X	Point of Service	59748	FL
4	103K00000X	Behavior Analyst	SW2625	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IMT 416	OTHER	FL	INTERN MFT
2	SW2625	OTHER	FL	SW

General Provider Information

NPI Number	:	1205295094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DRA BEHAVIORAL HEALTH CORP

Provider Business Mailing Address
First Line	:	6107 PALM DR
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-7577
Country	:	US
Telephone Number	:	954-394-2835
Fax Number	:

Provider Business Practice Location Address
First Line	:	6107 PALM DR
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-7577
Country	:	US
Telephone Number	:	954-394-2835
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DAISY RAVELO
Credential	:	INTERN MFT
Telephone Number	:	954-394-2835

Provider Enumeration Date	:	02/22/2016
Last Update Date	:	03/30/2017

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Directions to “DRA BEHAVIORAL HEALTH CORP ” Practice Location

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