Provider Demographics
NPI:1902432339
Name:BEHAVIORAL MIND WELLNESS: EVALUATION, PREVENTION & TREATMENT
Entity Type:Organization
Organization Name:BEHAVIORAL MIND WELLNESS: EVALUATION, PREVENTION & TREATMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:CAPELLA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGIST
Authorized Official - Phone:321-888-6965
Mailing Address - Street 1:417 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4154
Mailing Address - Country:US
Mailing Address - Phone:321-888-6965
Mailing Address - Fax:
Practice Address - Street 1:417 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4154
Practice Address - Country:US
Practice Address - Phone:321-888-6965
Practice Address - Fax:407-978-6520
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-17
Last Update Date:2021-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL024947100Medicaid