Provider Demographics
NPI:1861991481
Name:VIDA BEHAVIORAL HEALTH ASSOCIATES, LLC
Entity type:Organization
Organization Name:VIDA BEHAVIORAL HEALTH ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSSI
Authorized Official - Middle Name:
Authorized Official - Last Name:PEREZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:401-862-7292
Mailing Address - Street 1:3307 NORTHLAKE BLVD STE B104
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33403-1703
Mailing Address - Country:US
Mailing Address - Phone:401-862-7292
Mailing Address - Fax:
Practice Address - Street 1:3307 NORTHLAKE BLVD STE B104
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33403-1703
Practice Address - Country:US
Practice Address - Phone:561-618-5072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-09
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
FLMH13781101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLATN693995Medicaid