Provider Demographics
NPI:1235816083
Name:DEDICATED INNOVATIVE BEHAVIORAL SUPPORT
Entity Type:Organization
Organization Name:DEDICATED INNOVATIVE BEHAVIORAL SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-315-5031
Mailing Address - Street 1:14325 TREE SWALLOW WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD RANCH
Mailing Address - State:FL
Mailing Address - Zip Code:34202-8296
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14325 TREE SWALLOW WAY
Practice Address - Street 2:
Practice Address - City:LAKEWOOD RANCH
Practice Address - State:FL
Practice Address - Zip Code:34202-8296
Practice Address - Country:US
Practice Address - Phone:813-315-5031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health