Provider Demographics
NPI:1841649241
Name:FOUNDATIONS PEDIATRICS ASSESSMENT AND TREATMENT CENTER
Entity type:Organization
Organization Name:FOUNDATIONS PEDIATRICS ASSESSMENT AND TREATMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JILLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRIEST
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-895-3006
Mailing Address - Street 1:495 PROSPERITY LAKE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5045
Mailing Address - Country:US
Mailing Address - Phone:954-895-3006
Mailing Address - Fax:
Practice Address - Street 1:495 PROSPERITY LAKE DR STE 101
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5045
Practice Address - Country:US
Practice Address - Phone:954-895-3006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health