Provider Demographics
NPI:1629337258
Name:THE CHRYSALIS CENTER, INC
Entity Type:Organization
Organization Name:THE CHRYSALIS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF CONTRACTS
Authorized Official - Prefix:
Authorized Official - First Name:JO-ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRISCO
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:549-587-1008
Mailing Address - Street 1:3800 W BROWARD BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-1018
Mailing Address - Country:US
Mailing Address - Phone:954-587-1008
Mailing Address - Fax:954-587-0080
Practice Address - Street 1:1061 W OAKLAND PARK BLVD
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33311-1609
Practice Address - Country:US
Practice Address - Phone:954-792-9242
Practice Address - Fax:954-792-9243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-16
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251B00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL075982114Medicaid