Provider Demographics
NPI:1881216877
Name:PEDIATRIC BEHAVIORAL HEALTH ASSOCIATES, INC.
Entity Type:Organization
Organization Name:PEDIATRIC BEHAVIORAL HEALTH ASSOCIATES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:WOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCSW
Authorized Official - Phone:561-706-1004
Mailing Address - Street 1:2735 SE 140TH PL
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-2877
Mailing Address - Country:US
Mailing Address - Phone:561-706-1004
Mailing Address - Fax:561-892-0268
Practice Address - Street 1:5818 SE AGNEW RD
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-4020
Practice Address - Country:US
Practice Address - Phone:561-706-1004
Practice Address - Fax:561-892-0268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-12
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102843600Medicaid