Provider Demographics
NPI:1861953523
Name:PEDIATRIC BEHAVIORAL HEALTH ASSOCIATES, INC.
Entity type:Organization
Organization Name:PEDIATRIC BEHAVIORAL HEALTH ASSOCIATES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:PHD,LCSW
Authorized Official - Phone:561-706-1004
Mailing Address - Street 1:2735 SE 140TH PL
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-2877
Mailing Address - Country:US
Mailing Address - Phone:561-715-5910
Mailing Address - Fax:561-892-0268
Practice Address - Street 1:5818 SE AGNEW RD
Practice Address - Street 2:
Practice Address - City:BELLEVIEW
Practice Address - State:FL
Practice Address - Zip Code:34420-4020
Practice Address - Country:US
Practice Address - Phone:561-706-1004
Practice Address - Fax:561-892-0268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-26
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & BehavioralGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767023100Medicaid