Provider Demographics
NPI:1427508100
Name:FSBA,INC
Entity type:Organization
Organization Name:FSBA,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:DEBORAH
Authorized Official - Last Name:CLIETT
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:352-278-1920
Mailing Address - Street 1:19802 OLD BELLAMY RD
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-3867
Mailing Address - Country:US
Mailing Address - Phone:352-278-1920
Mailing Address - Fax:
Practice Address - Street 1:19802 OLD BELLAMY RD
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-3867
Practice Address - Country:US
Practice Address - Phone:352-278-1920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH2814101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty