Provider Demographics
NPI:1902802002
Name:LIFESTREAM BEHAVIORAL CENTER INC
Entity Type:Organization
Organization Name:LIFESTREAM BEHAVIORAL CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOZIER
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:352-315-7532
Mailing Address - Street 1:PO BOX 491000
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-1000
Mailing Address - Country:US
Mailing Address - Phone:352-315-7500
Mailing Address - Fax:352-360-6595
Practice Address - Street 1:2020 TALLEY RD
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3426
Practice Address - Country:US
Practice Address - Phone:352-315-7800
Practice Address - Fax:352-315-6595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-23
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC2200X, 2084P0800X, 251B00000X, 261QM0801X, 323P00000X
FL4075283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes283Q00000XHospitalsPsychiatric Hospital
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060334100Medicaid
FL151443OtherWELLCARE PROVIDER #
FL060334108Medicaid
FL060334102Medicaid
FL98270OtherBCBS OUTPATIENT NUMBER
FLE-83OtherBCBS INPATIENT NUMBER
FL024576301Medicaid
FL060334105Medicaid
FL360181100Medicaid
FL98270Medicare ID - Type UnspecifiedPART B NUMBER
FL060334105Medicaid