Provider Demographics
NPI:1639793326
Name:ADVANCED BEHAVIORAL CLINICIANS, LLC
Entity Type:Organization
Organization Name:ADVANCED BEHAVIORAL CLINICIANS, LLC
Other - Org Name:ADVANCD BEHAVIORAL CLINICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ADAIR
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:DEICKE
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:727-239-9938
Mailing Address - Street 1:20 MEADOWBROOK LN
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:MA
Mailing Address - Zip Code:01069-1134
Mailing Address - Country:US
Mailing Address - Phone:941-870-3600
Mailing Address - Fax:727-998-8401
Practice Address - Street 1:2650 BAHIA VISTA ST STE 209
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2625
Practice Address - Country:US
Practice Address - Phone:941-870-3600
Practice Address - Fax:727-998-8401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-29
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008642300Medicaid