Provider Demographics
NPI:1083167530
Name:CARROUSEL THERAPY CENTER CORPORATION
Entity Type:Organization
Organization Name:CARROUSEL THERAPY CENTER CORPORATION
Other - Org Name:CARROUSEL BEHAVIORAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVERA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-414-8409
Mailing Address - Street 1:2520 SAND MINE RD
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-3402
Mailing Address - Country:US
Mailing Address - Phone:407-891-3054
Mailing Address - Fax:800-477-7678
Practice Address - Street 1:3201 BUDINGER AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-7203
Practice Address - Country:US
Practice Address - Phone:407-891-3054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR882235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003711300Medicaid