Provider Demographics
NPI:1932543634
Name:FIRST IMPRESSIONS COMMUNITY DEVELOPEMENT CORP.
Entity type:Organization
Organization Name:FIRST IMPRESSIONS COMMUNITY DEVELOPEMENT CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHATARIA
Authorized Official - Middle Name:BRIDGES
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-572-6250
Mailing Address - Street 1:20101 NW 34TH CT
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33056-1768
Mailing Address - Country:US
Mailing Address - Phone:561-572-6250
Mailing Address - Fax:305-248-4284
Practice Address - Street 1:13366 SW 288TH ST
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-1927
Practice Address - Country:US
Practice Address - Phone:561-572-6250
Practice Address - Fax:305-248-4284
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
FL251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health