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3550 W Waters Ave Ste 264 Tampa FL 33614-2773 | |
| (813) 525-5057 | |
| (813) 227-9848 |
| Full Name | |
|---|---|
| Speciality | Community/Behavioral Health |
| Location | 3550 W Waters Ave Ste 264, Tampa, Florida |
| Authorized Official Name and Position | Robin Foster (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 8134427505 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
4826 Cheval Blvd Lutz FL 33558-5337 Ph: (813) 442-7505 | 3550 W Waters Ave Ste 264 Tampa FL 33614-2773 Ph: (813) 525-5057 |
| NPI Number | 1275953291 |
|---|---|
| Provider Enumeration Date | 04/17/2014 |
| Last Update Date | 03/06/2024 |
| Certification Date | 03/06/2024 |
| Medicare PECOS PAC ID | 9133563315 |
|---|---|
| Medicare Enrollment ID | O20240215001520 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1275953291 | NPI | - | NPPES |
| Z04K4 | Other | FL | FL BLUE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | MH11405 (Florida) | Secondary |
| 251S00000X | Community/behavioral Health | (* (Not Available)) | Primary |
| Provider Name | Orlando Lazaro Ruano |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1013021138 PECOS PAC ID: 0749254225 Enrollment ID: I20040820000868 |
| Provider Name | Ajay Desai |
|---|---|
| Provider Type | Practitioner - Pediatric Medicine |
| Provider Identifiers | NPI Number: 1295962462 PECOS PAC ID: 7618140476 Enrollment ID: I20160316002397 |
| Provider Name | Kimberly Marie Hymiller |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1447864921 PECOS PAC ID: 4385054626 Enrollment ID: I20201028000176 |
| Provider Name | Erica Evans |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1801204193 PECOS PAC ID: 5698097822 Enrollment ID: I20201111000667 |
| Provider Name | Karen A Bebnowski |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1538415104 PECOS PAC ID: 7911306113 Enrollment ID: I20210520000078 |
| Provider Name | Jerika Terese Perry |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1922762467 PECOS PAC ID: 0446643597 Enrollment ID: I20220214000054 |
| Provider Name | Michael Davidson |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1851921928 PECOS PAC ID: 9133505837 Enrollment ID: I20221004001414 |
| Provider Name | Robin S Foster |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1063761781 PECOS PAC ID: 4183901994 Enrollment ID: I20240424001868 |
| Provider Name | Cheryl Heather Whitmire |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1053569780 PECOS PAC ID: 3678016813 Enrollment ID: I20240617002109 |
| Provider Name | Tara Wehr |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1356164677 PECOS PAC ID: 7012443187 Enrollment ID: I20241212001508 |
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