Provider Demographics
NPI:1770511479
Name:ATLANTIC MENTAL HEALTH PROGRAM, INC
Entity Type:Organization
Organization Name:ATLANTIC MENTAL HEALTH PROGRAM, INC
Other - Org Name:HOMESTEAD BEHAVIORAL CLINIC, HBC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AIDELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-248-3488
Mailing Address - Street 1:654 NE 9TH PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-4934
Mailing Address - Country:US
Mailing Address - Phone:305-248-3488
Mailing Address - Fax:305-248-3488
Practice Address - Street 1:654 NE 9TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030
Practice Address - Country:US
Practice Address - Phone:305-248-3488
Practice Address - Fax:305-248-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
FLHCC4181251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004814500Medicaid
FL276194700Medicaid