Provider Demographics
NPI:1508222324
Name:BEHAVIORAL HEALTH SCIENCE OF WEST FLORIDA, LLC
Entity Type:Organization
Organization Name:BEHAVIORAL HEALTH SCIENCE OF WEST FLORIDA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MARKET MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TED
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:DORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-283-8811
Mailing Address - Street 1:508 S HABANA AVE STE 380
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4144
Mailing Address - Country:US
Mailing Address - Phone:813-872-0457
Mailing Address - Fax:813-877-7691
Practice Address - Street 1:508 S HABANA AVE STE 380
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4144
Practice Address - Country:US
Practice Address - Phone:813-872-0457
Practice Address - Fax:813-877-7691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1124012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME112401OtherFLORIDA MEDICAL LICENSING BOARD