Provider Demographics
NPI:1679562797
Name:PROFESSIONAL PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:PROFESSIONAL PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELBA
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-734-1273
Mailing Address - Street 1:8614 BRACKENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-8628
Mailing Address - Country:US
Mailing Address - Phone:787-645-7302
Mailing Address - Fax:
Practice Address - Street 1:5449 S SEMORAN BLVD STE 20
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32822-1778
Practice Address - Country:US
Practice Address - Phone:407-734-1273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-20
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
PR67222084P0800X, 2084P0800X
FL261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010942000Medicaid
PR88723OtherPSYCHIATRIST
PR88723OtherPSYCHIATRIST
80211Medicare PIN