Provider Demographics
NPI:1659613776
Name:LIFESTREAM BEHAVIORAL CENTER INC
Entity Type:Organization
Organization Name:LIFESTREAM BEHAVIORAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CPA
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOZIER
Authorized Official - Suffix:
Authorized Official - Credentials:CFO
Authorized Official - Phone:352-315-7532
Mailing Address - Street 1:PO BOX 491000
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-1000
Mailing Address - Country:US
Mailing Address - Phone:352-315-7500
Mailing Address - Fax:352-360-6582
Practice Address - Street 1:215 N 3RD ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5105
Practice Address - Country:US
Practice Address - Phone:352-315-7900
Practice Address - Fax:352-360-6582
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESTREAM BEHAVIORAL CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024576301Medicaid
FL98270OtherMEDICARE GROUP NUMBER