Provider Demographics
NPI:1528890126
Name:BLACK MENTAL HEALTH TAMPA BAY LLC
Entity type:Organization
Organization Name:BLACK MENTAL HEALTH TAMPA BAY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:
Authorized Official - First Name:RAVEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-451-4359
Mailing Address - Street 1:3975 ADDLESTONE AVE UNIT 113
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-5582
Mailing Address - Country:US
Mailing Address - Phone:813-451-4359
Mailing Address - Fax:813-451-4359
Practice Address - Street 1:7402 N 56TH ST STE 355
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-7700
Practice Address - Country:US
Practice Address - Phone:813-451-4359
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health