Provider Demographics
NPI:1639229362
Name:GROWING WELL FAMILY BEHAVIORAL SERVICES
Entity Type:Organization
Organization Name:GROWING WELL FAMILY BEHAVIORAL SERVICES
Other - Org Name:GROWING WELL FBS
Other - Org Type:Other Name
Authorized Official - Title/Position:SCHOOL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:EDS
Authorized Official - Phone:352-465-2444
Mailing Address - Street 1:20114 E PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:DUNNELLON
Mailing Address - State:FL
Mailing Address - Zip Code:34432-6033
Mailing Address - Country:US
Mailing Address - Phone:352-465-2444
Mailing Address - Fax:352-465-7854
Practice Address - Street 1:20114 EAST PENNSYLVANIA AVENUE
Practice Address - Street 2:
Practice Address - City:DUNNELLON
Practice Address - State:FL
Practice Address - Zip Code:34432
Practice Address - Country:US
Practice Address - Phone:352-465-2444
Practice Address - Fax:352-465-7854
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSS830103TS0200X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691219296OtherSTATE OF FL AGENCY FOR PE
FL691219298OtherSTATE OF FL AGENCY FOR PE