Provider Demographics
NPI:1891051132
Name:AGENCY PROVIDER SERVICES FOR INDEPENDENCE LLC
Entity Type:Organization
Organization Name:AGENCY PROVIDER SERVICES FOR INDEPENDENCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANNALYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:CENKNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-890-7014
Mailing Address - Street 1:PO BOX 101369
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32910-1369
Mailing Address - Country:US
Mailing Address - Phone:321-890-7014
Mailing Address - Fax:321-722-3760
Practice Address - Street 1:1418 NORMAN ST NE
Practice Address - Street 2:UNIT#1
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2267
Practice Address - Country:US
Practice Address - Phone:321-890-7014
Practice Address - Fax:321-722-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-11
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL11000062706251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health