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50 N Laura St Suite 2500 Jacksonville FL 32202-3664 | |
| (813) 754-5555 | |
| (813) 754-5552 |
| Full Name | |
|---|---|
| Speciality | Counselor - Mental Health |
| Location | 50 N Laura St, Jacksonville, Florida |
| Authorized Official Name and Position | Edward A Waller (COO) |
| Authorized Official Contact | 8137545555 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1001 E Baker St Suite 202 Plant City FL 33563-3700 Ph: (813) 754-5555 | 50 N Laura St Suite 2500 Jacksonville FL 32202-3664 Ph: (813) 754-5555 |
| NPI Number | 1437550266 |
|---|---|
| Provider Enumeration Date | 09/11/2014 |
| Last Update Date | 09/11/2014 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437550266 | NPI | - | NPPES |
| 006323200 | Medicaid | FL | |
| 007813200 | Medicaid | FL | |
| 1326311085 | Other | FL | NPI TAMPA LOCATION |
| 1053658153 | Other | FL | NPI- ORLANDO LOCATION |
| 1073871208 | Other | FL | NPI- FORT MYERS LOCATION |
| 007862400 | Medicaid | FL |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | 05 (Florida) | Primary |
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