Provider Demographics
NPI:1205295094
Name:DRA BEHAVIORAL HEALTH CORP
Entity type:Organization
Organization Name:DRA BEHAVIORAL HEALTH CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAISY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAVELO
Authorized Official - Suffix:
Authorized Official - Credentials:INTERN MFT
Authorized Official - Phone:954-394-2835
Mailing Address - Street 1:6107 PALM DR
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-7577
Mailing Address - Country:US
Mailing Address - Phone:954-394-2835
Mailing Address - Fax:
Practice Address - Street 1:6107 PALM DR
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-7577
Practice Address - Country:US
Practice Address - Phone:954-394-2835
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:940003472951
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-22
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 2625252Y00000X
FL59748251V00000X, 305S00000X
FLSW2625103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Single Specialty
No251V00000XAgenciesVoluntary or Charitable
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMT 416OtherINTERN MFT
FLSW2625OtherSW