Provider Demographics
NPI:1417435165
Name:SOLACE BEHAVIORAL HEALTH PSYCHIATRIC & SUBSTANCE ABUSE IOP
Entity Type:Organization
Organization Name:SOLACE BEHAVIORAL HEALTH PSYCHIATRIC & SUBSTANCE ABUSE IOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SPADAFORA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-678-5550
Mailing Address - Street 1:17222 HOSPITAL BLVD STE 226
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34601-8925
Mailing Address - Country:US
Mailing Address - Phone:352-678-5550
Mailing Address - Fax:352-678-5551
Practice Address - Street 1:8449 COBB RD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34601-8704
Practice Address - Country:US
Practice Address - Phone:352-678-5550
Practice Address - Fax:352-678-5551
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOLACE BEHAVIORAL HEALTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-04
Last Update Date:2018-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010023100Medicaid
FLGW088AOtherMEDICARE