Provider Demographics
NPI:1679150742
Name:LOYAL SOURCE WORLDWIDE, INC.
Entity type:Organization
Organization Name:LOYAL SOURCE WORLDWIDE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH CLINIC DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:LELLO
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:407-707-9781
Mailing Address - Street 1:12612 CHALLENGER PKWY STE 365
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-2784
Mailing Address - Country:US
Mailing Address - Phone:407-707-9781
Mailing Address - Fax:234-241-2258
Practice Address - Street 1:12612 CHALLENGER PKWY STE 365
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-2784
Practice Address - Country:US
Practice Address - Phone:407-707-9781
Practice Address - Fax:234-241-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-25
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health