Provider Demographics
NPI:1518634054
Name:DAVENPORT BEHAVIORAL CENTER LLC
Entity Type:Organization
Organization Name:DAVENPORT BEHAVIORAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MS
Authorized Official - First Name:FRAINELYS
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUZ
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:321-278-4084
Mailing Address - Street 1:109 AMBERSWEET WAY
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33897-8418
Mailing Address - Country:US
Mailing Address - Phone:321-663-6375
Mailing Address - Fax:
Practice Address - Street 1:19 N 6TH STREET
Practice Address - Street 2:19A
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844
Practice Address - Country:US
Practice Address - Phone:321-663-6375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-24
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty