Provider Demographics
NPI:1114991544
Name:DOUGLAS GARDENS COMMUNITY MENTAL HEALTH CENTER OF MIAMI BEACH, INC.
Entity Type:Organization
Organization Name:DOUGLAS GARDENS COMMUNITY MENTAL HEALTH CENTER OF MIAMI BEACH, INC.
Other - Org Name:DOUGLAS GARDENS CMHC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:MACC
Authorized Official - Phone:305-531-5341
Mailing Address - Street 1:1680 MERIDIAN AVE STE 501
Mailing Address - Street 2:
Mailing Address - City:MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33139-2719
Mailing Address - Country:US
Mailing Address - Phone:305-531-5341
Mailing Address - Fax:305-532-5322
Practice Address - Street 1:1680 MERIDIAN AVE
Practice Address - Street 2:SUITE 501
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139
Practice Address - Country:US
Practice Address - Phone:305-531-5341
Practice Address - Fax:305-532-5322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-14
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLKH909101YM0800X, 251B00000X, 261QM0801X, 310500000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060289200Medicaid
FL060289203Medicaid
FL090289204Medicaid
FL100730100Medicaid
FL060289201Medicaid
FL060289203Medicaid