Provider Demographics
NPI:1891024022
Name:PEDIATRIC HEALTH CHOICE
Entity Type:Organization
Organization Name:PEDIATRIC HEALTH CHOICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PREESIDENT OF BEHAVIORAL HEALT
Authorized Official - Prefix:
Authorized Official - First Name:N
Authorized Official - Middle Name:
Authorized Official - Last Name:A
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-769-1170
Mailing Address - Street 1:4602-C NORTH ARMENIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8509 BENJAMIN RD STE A-D
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-1224
Practice Address - Country:US
Practice Address - Phone:813-769-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-09-5768103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL679096896Medicaid