Provider Demographics
NPI:1750884003
Name:MGB BEHAVIORAL HEALTH SERVICES
Entity type:Organization
Organization Name:MGB BEHAVIORAL HEALTH SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CASE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:BATEAU
Authorized Official - Suffix:
Authorized Official - Credentials:M S
Authorized Official - Phone:954-601-6078
Mailing Address - Street 1:PO BOX 26121
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33320-6121
Mailing Address - Country:US
Mailing Address - Phone:954-601-6078
Mailing Address - Fax:
Practice Address - Street 1:4780 N W 24 COURT
Practice Address - Street 2:C215
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33313
Practice Address - Country:US
Practice Address - Phone:954-601-6078
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-13
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1588102859Medicaid