Provider Demographics
NPI:1326311085
Name:HEALING EDUCATIONAL ALTERNATIVES FOR DESERVING STUDENTS
Entity Type:Organization
Organization Name:HEALING EDUCATIONAL ALTERNATIVES FOR DESERVING STUDENTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-495-3874
Mailing Address - Street 1:1001 E BAKER ST
Mailing Address - Street 2:#100
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-3700
Mailing Address - Country:US
Mailing Address - Phone:813-956-3781
Mailing Address - Fax:
Practice Address - Street 1:1001 E BAKER ST STE 100
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-3700
Practice Address - Country:US
Practice Address - Phone:813-754-5555
Practice Address - Fax:813-754-5552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251S00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007813200Medicaid