Provider Demographics
NPI:1831492669
Name:BIG BEND COMMUNITY INTERVENTION CENTER
Entity Type:Organization
Organization Name:BIG BEND COMMUNITY INTERVENTION CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALISHA
Authorized Official - Middle Name:T
Authorized Official - Last Name:BURNS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:850-508-1870
Mailing Address - Street 1:PO BOX 1237
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32353-1237
Mailing Address - Country:US
Mailing Address - Phone:850-508-1870
Mailing Address - Fax:850-539-9303
Practice Address - Street 1:155 SLASH CIR
Practice Address - Street 2:
Practice Address - City:MIDWAY
Practice Address - State:FL
Practice Address - Zip Code:32343-4258
Practice Address - Country:US
Practice Address - Phone:850-508-1870
Practice Address - Fax:850-539-9303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 9723251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health