Provider Demographics
NPI:1669236055
Name:PROFESSIONAL BEHAVIORAL SERVICES, LLC
Entity type:Organization
Organization Name:PROFESSIONAL BEHAVIORAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES FLORES
Authorized Official - Suffix:
Authorized Official - Credentials:TCM
Authorized Official - Phone:402-222-8145
Mailing Address - Street 1:8614 BRACKENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32829-8628
Mailing Address - Country:US
Mailing Address - Phone:787-645-7302
Mailing Address - Fax:
Practice Address - Street 1:110 LEXINGTON GREEN LN
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-1025
Practice Address - Country:US
Practice Address - Phone:407-734-1273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty