Provider Demographics
NPI:1023071198
Name:WINDWARD BEHAVIORAL CARE, INC.
Entity type:Organization
Organization Name:WINDWARD BEHAVIORAL CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:BENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:386-258-5050
Mailing Address - Street 1:P.O. BOX 2196
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32115-2196
Mailing Address - Country:US
Mailing Address - Phone:386-258-5050
Mailing Address - Fax:386-252-3506
Practice Address - Street 1:245 S. AMELIA AVENUE
Practice Address - Street 2:BLDG. A
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-5913
Practice Address - Country:US
Practice Address - Phone:386-258-5050
Practice Address - Fax:386-252-3506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-10
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL324500000X324500000X
324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0299804-01Medicaid