Provider Demographics
NPI:1437550266
Name:HEALING EDUCATIONAL ALTERNATIVES FOR DESERVING STUDENTS
Entity Type:Organization
Organization Name:HEALING EDUCATIONAL ALTERNATIVES FOR DESERVING STUDENTS
Other - Org Name:HEADS
Other - Org Type:Other Name
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLER
Authorized Official - Suffix:
Authorized Official - Credentials:MED
Authorized Official - Phone:813-754-5555
Mailing Address - Street 1:1001 E BAKER ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-3700
Mailing Address - Country:US
Mailing Address - Phone:813-754-5555
Mailing Address - Fax:813-754-5552
Practice Address - Street 1:50 N LAURA ST
Practice Address - Street 2:SUITE 2500
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32202-3664
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:2014-09-11
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL05101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006323200Medicaid
FL007813200Medicaid
FL1326311085OtherNPI TAMPA LOCATION
FL1053658153OtherNPI- ORLANDO LOCATION
FL1073871208OtherNPI- FORT MYERS LOCATION
FL007862400Medicaid