Provider Demographics
NPI:1407403397
Name:ASCEND BEHAVIORAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:ASCEND BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROQUE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:786-385-5337
Mailing Address - Street 1:6360 PRESIDENTIAL CT STE 3
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3501
Mailing Address - Country:US
Mailing Address - Phone:786-377-5643
Mailing Address - Fax:786-802-2011
Practice Address - Street 1:6360 PRESIDENTIAL CT STE 3
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3501
Practice Address - Country:US
Practice Address - Phone:786-377-5643
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-24
Last Update Date:2022-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014875800Medicaid