Provider Demographics
NPI:1508368192
Name:LIVE OAK BEHAVIORAL HEALTH PA
Entity Type:Organization
Organization Name:LIVE OAK BEHAVIORAL HEALTH PA
Other - Org Name:LIVE OAK BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PAULSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:407-756-2084
Mailing Address - Street 1:341 N MAITLAND AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-4761
Mailing Address - Country:US
Mailing Address - Phone:407-756-2084
Mailing Address - Fax:
Practice Address - Street 1:341 N MAITLAND AVE STE 120
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-4761
Practice Address - Country:US
Practice Address - Phone:407-756-2084
Practice Address - Fax:866-495-2994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY9901103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty