Provider Demographics
NPI:1194018424
Name:OPTIMUM MENTAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:OPTIMUM MENTAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LASCELLS
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:407-703-3569
Mailing Address - Street 1:559 HIAWATHA PALM PL
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-3315
Mailing Address - Country:US
Mailing Address - Phone:407-703-3569
Mailing Address - Fax:
Practice Address - Street 1:559 HIAWATHA PALM PL
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-3315
Practice Address - Country:US
Practice Address - Phone:407-703-3569
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-19
Last Update Date:2013-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW84171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty