MEDICARE: BEHAVIORAL HEALTH SCIENCE OF WEST FLORIDA, LLC

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	2084P0800X	Psychiatry Physician	ME112401	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ME112401	OTHER	FL	FLORIDA MEDICAL LICENSING BOARD

General Provider Information

NPI Number	:	1508222324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEHAVIORAL HEALTH SCIENCE OF WEST FLORIDA, LLC

Provider Business Mailing Address
First Line	:	508 S HABANA AVE STE 380
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4144
Country	:	US
Telephone Number	:	813-872-0457
Fax Number	:	813-877-7691

Provider Business Practice Location Address
First Line	:	508 S HABANA AVE STE 380
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33609-4144
Country	:	US
Telephone Number	:	813-872-0457
Fax Number	:	813-877-7691

Authorized Official
Title or Position	:	MARKET MANAGER
Name	:	TED MARK DORTON
Credential	:
Telephone Number	:	813-283-8811

Provider Enumeration Date	:	01/08/2016
Last Update Date	:	01/08/2016

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