MEDICARE: PRACTITIONERS ALLIANCE BEHAVIORAL

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1346869765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRACTITIONERS ALLIANCE BEHAVIORAL

Provider Business Mailing Address
First Line	:	7450 CYPRESS GARDENS BLVD STE 7504
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-6200
Country	:	US
Telephone Number	:	863-875-6063
Fax Number	:	863-875-6086

Provider Business Practice Location Address
First Line	:	7504 CYPRESS GARDENS BLVD STE 7504
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33884-3200
Country	:	US
Telephone Number	:	863-875-6063
Fax Number	:	863-875-6086

Authorized Official
Title or Position	:	PMHNP-BC
Name	:	PAUL ESTRADA
Credential	:	APRN
Telephone Number	:	863-875-6063

Provider Enumeration Date	:	04/15/2020
Last Update Date	:	01/14/2022

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