Provider Demographics
NPI:1245620327
Name:MAJESTIC BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:MAJESTIC BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LA TOYA
Authorized Official - Middle Name:SHARNETT
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CCJAP, CAP
Authorized Official - Phone:386-253-9391
Mailing Address - Street 1:1057 MASON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-4611
Mailing Address - Country:US
Mailing Address - Phone:386-253-9391
Mailing Address - Fax:386-253-9391
Practice Address - Street 1:1057 MASON AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-4611
Practice Address - Country:US
Practice Address - Phone:386-253-9391
Practice Address - Fax:386-253-9391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-28
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0764AD478701251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health