Provider Demographics
NPI:1972878437
Name:PROVIDENCE ACADEMY, INC
Entity Type:Organization
Organization Name:PROVIDENCE ACADEMY, INC
Other - Org Name:PROVIDENCE FOUNDATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDATION PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:NARET
Authorized Official - Last Name:BRACCIA
Authorized Official - Suffix:
Authorized Official - Credentials:MA,CAS,ABSNP, LSP
Authorized Official - Phone:407-382-5551
Mailing Address - Street 1:1561 S ALAFAYA TRL
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32828-8956
Mailing Address - Country:US
Mailing Address - Phone:407-382-5551
Mailing Address - Fax:407-382-5637
Practice Address - Street 1:1561 S ALAFAYA TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8956
Practice Address - Country:US
Practice Address - Phone:407-382-5551
Practice Address - Fax:407-382-5637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001021700Medicaid