Provider Demographics
NPI:1235505355
Name:FLAGLER HOSPITAL INC. (BEHAVIORAL HEALTH)
Entity Type:Organization
Organization Name:FLAGLER HOSPITAL INC. (BEHAVIORAL HEALTH)
Other - Org Name:FLAGLER HOSPITAL BEHAVIORAL HEALTH ASSOCIATES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PSYCHIATRIC UR COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:DELANO
Authorized Official - Last Name:BROUN
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-819-5288
Mailing Address - Street 1:201 HEALTH PARK BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5796
Mailing Address - Country:US
Mailing Address - Phone:904-819-2295
Mailing Address - Fax:904-819-2294
Practice Address - Street 1:201 HEALTH PARK BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5796
Practice Address - Country:US
Practice Address - Phone:904-819-2295
Practice Address - Fax:904-819-2294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FLAGLER HOSPITAL INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-12
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 163W00000X, 2084P0800X
FL4392261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010171100Medicaid
FL010171100Medicaid