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4107 W Spruce St Ste 100 Tampa FL 33607-2346 | |
| (813) 636-8811 | |
| (813) 636-8855 |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 4107 W Spruce St Ste 100, Tampa, Florida |
| Authorized Official Name and Position | Aleida Cruz (ADMINISTRATOR) |
| Authorized Official Contact | 8136368811 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4107 W Spruce St Ste 100 Tampa FL 33607-2346 Ph: (813) 636-8811 | 4107 W Spruce St Ste 100 Tampa FL 33607-2346 Ph: (813) 636-8811 |
| NPI Number | 1184900631 |
|---|---|
| Provider Enumeration Date | 10/28/2011 |
| Last Update Date | 07/26/2023 |
| Certification Date | 07/26/2023 |
| Medicare PECOS PAC ID | 5698936037 |
|---|---|
| Medicare Enrollment ID | O20120412000144 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1184900631 | NPI | - | NPPES |
| 105204200 | Medicaid | FL | |
| DW0247 | Other | FL | RAILROAD MEDICARE GROUP PTAN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Sarah Klein Reid |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1053462291 PECOS PAC ID: 9537218532 Enrollment ID: I20090521000601 |
| Provider Name | Susan L Roux |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1366613309 PECOS PAC ID: 4486703204 Enrollment ID: I20090527000092 |
| Provider Name | Lois I Gonzalez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164536439 PECOS PAC ID: 1850420738 Enrollment ID: I20100602000814 |
| Provider Name | Victor Hong |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1134155401 PECOS PAC ID: 3274729868 Enrollment ID: I20101122000650 |
| Provider Name | Dorit G Breiter |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194923169 PECOS PAC ID: 1658559737 Enrollment ID: I20110620000153 |
| Provider Name | Brandon Kopkin |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1710467238 PECOS PAC ID: 9032455639 Enrollment ID: I20190117002151 |
| Provider Name | Sarah Powell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306249438 PECOS PAC ID: 7113243551 Enrollment ID: I20191217001102 |
| Provider Name | Nicole Elizabeth Flory |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1669063749 PECOS PAC ID: 7517338726 Enrollment ID: I20230126001903 |
| Provider Name | Lourdes Bernardete Lozano Gonzalez |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1396433728 PECOS PAC ID: 4284089178 Enrollment ID: I20231012002193 |
| Provider Name | Sandralee Gordon Foley |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1578861134 PECOS PAC ID: 2860858669 Enrollment ID: I20231114000405 |
| Provider Name | Ana Maria Rubio |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1275065377 PECOS PAC ID: 5294182093 Enrollment ID: I20231116001525 |
| Provider Name | Alexia B Allen |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1730694456 PECOS PAC ID: 1052769726 Enrollment ID: I20231120001156 |
| Provider Name | Jason A Versace |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1386247690 PECOS PAC ID: 0244688828 Enrollment ID: I20231120002031 |
| Provider Name | Andrea L Barreto |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1700054053 PECOS PAC ID: 4981053519 Enrollment ID: I20231208000113 |
| Provider Name | Jessica D Lopez |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1629245626 PECOS PAC ID: 4385093699 Enrollment ID: I20231212003210 |
| Provider Name | Alexandra Rae Maynard |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1538638465 PECOS PAC ID: 1153770466 Enrollment ID: I20231212003384 |
| Provider Name | Chelsea Lynn Geller |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1184272080 PECOS PAC ID: 4789031444 Enrollment ID: I20231215000144 |
| Provider Name | Kimberly Clark |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1497236301 PECOS PAC ID: 0446798524 Enrollment ID: I20240820004192 |
| Provider Name | William R Fitzgerald |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1770174229 PECOS PAC ID: 6002355054 Enrollment ID: I20240822001819 |
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