Provider Demographics
NPI:1093041154
Name:CENTER FOR INDEPENDENT LIVING IN CENTRAL FLORIDA
Entity Type:Organization
Organization Name:CENTER FOR INDEPENDENT LIVING IN CENTRAL FLORIDA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:P
Authorized Official - Last Name:JACK
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:407-623-1070
Mailing Address - Street 1:720 N. DENNING DR.
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789
Mailing Address - Country:US
Mailing Address - Phone:407-623-1070
Mailing Address - Fax:407-623-1390
Practice Address - Street 1:720 N. DENNING DR.
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789
Practice Address - Country:US
Practice Address - Phone:407-623-1070
Practice Address - Fax:407-623-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-26
Last Update Date:2009-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8933251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health