Provider Demographics
NPI:1982922829
Name:INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC
Other - Org Name:IMPACT BEHAVIORAL HEALTH LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MIGNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-656-2006
Mailing Address - Street 1:1965 CAPITAL CIR NE STE 200
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-8402
Mailing Address - Country:US
Mailing Address - Phone:850-656-2006
Mailing Address - Fax:850-656-2820
Practice Address - Street 1:1965 CAPITAL CIR NE
Practice Address - Street 2:SUITE 102
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-8401
Practice Address - Country:US
Practice Address - Phone:850-671-4600
Practice Address - Fax:850-878-2863
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERNAL MEDICINE AND PEDIATRICS ASSOCIATESOF TALLAHASSEE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-05-16
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8447101Y00000X, 101YM0800X
FL6702104100000X, 1041C0700X
FL324500000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL600680931OtherMAGELLAN
GA2386OtherLICENSED PROFESSIONAL COUNSELOR
GA648299630AMedicaid
FL003214900Medicaid
FL8447OtherLICENSED MENTAL HEALTH COUNSELOR