Provider Demographics
NPI:1598497885
Name:LAKELAND BEHAVIOR SERVICES, LLC
Entity Type:Organization
Organization Name:LAKELAND BEHAVIOR SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:YANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-602-0904
Mailing Address - Street 1:3745 HILL ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-4338
Mailing Address - Country:US
Mailing Address - Phone:786-602-0904
Mailing Address - Fax:
Practice Address - Street 1:3745 HILL ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-4338
Practice Address - Country:US
Practice Address - Phone:786-602-0904
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid