| Live Oak Behavioral Health | |
|
341 N Maitland Ave Ste 120 Maitland FL 32751-4761 | |
| (407) 756-2084 | |
| (866) 495-2994 |
| Full Name | Live Oak Behavioral Health |
|---|---|
| Speciality | Psychologist |
| Location | 341 N Maitland Ave Ste 120, Maitland, Florida |
| Authorized Official Name and Position | Daniel Paulson (CO-OWNER) |
| Authorized Official Contact | 4077562084 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Live Oak Behavioral Health 341 N Maitland Ave Ste 120 Maitland FL 32751-4761 Ph: (407) 756-2084 | Live Oak Behavioral Health 341 N Maitland Ave Ste 120 Maitland FL 32751-4761 Ph: (407) 756-2084 |
| NPI Number | 1508368192 |
|---|---|
| Provider Enumeration Date | 02/28/2018 |
| Last Update Date | 10/05/2020 |
| Certification Date | 10/05/2020 |
| Medicare PECOS PAC ID | 9032525969 |
|---|---|
| Medicare Enrollment ID | O20210301002205 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1508368192 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TB0200X | Psychologist - Cognitive & Behavioral | PY9901 (Florida) | Primary |
| Provider Name | Daniel Lee Paulson |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1659883239 PECOS PAC ID: 0941616874 Enrollment ID: I20210301002400 |
| Provider Name | Tracy Charisse Wharton |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1780103440 PECOS PAC ID: 5496155970 Enrollment ID: I20210621003023 |
| Provider Name | Robert D Dvorak |
|---|---|
| Provider Type | Practitioner - Clinical Psychologist |
| Provider Identifiers | NPI Number: 1437572534 PECOS PAC ID: 7416180179 Enrollment ID: I20210821000223 |
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