Provider Demographics
NPI:1487804142
Name:CANOPY COVE
Entity type:Organization
Organization Name:CANOPY COVE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:850-893-8800
Mailing Address - Street 1:13305 MAHAN DR
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-8698
Mailing Address - Country:US
Mailing Address - Phone:850-893-8800
Mailing Address - Fax:
Practice Address - Street 1:13305 MAHAN DR
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-8698
Practice Address - Country:US
Practice Address - Phone:850-893-8800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DR. LYNDA BROGDON PHD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-30
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY4363323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility