Provider Demographics
NPI:1710414511
Name:KIDS HOUSE OF SEMINOLE
Entity Type:Organization
Organization Name:KIDS HOUSE OF SEMINOLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:CONUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-324-3036
Mailing Address - Street 1:5467 RONALD REAGAN BLVD
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-6332
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5467 RONALD REAGAN BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32773-6332
Practice Address - Country:US
Practice Address - Phone:407-324-3036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15952251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health