Provider Demographics
NPI:1356095202
Name:MOCKINGBIRD QUALITY CARE BEHAVIOR FOCUS, LLC
Entity Type:Organization
Organization Name:MOCKINGBIRD QUALITY CARE BEHAVIOR FOCUS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:WAIVER PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DAMION
Authorized Official - Middle Name:S
Authorized Official - Last Name:PETERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-796-1567
Mailing Address - Street 1:5921 RIVA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33544-6517
Mailing Address - Country:US
Mailing Address - Phone:831-796-1567
Mailing Address - Fax:
Practice Address - Street 1:5921 RIVA RIDGE DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33544-6517
Practice Address - Country:US
Practice Address - Phone:831-796-1567
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017344800Medicaid