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3733 University Blvd W Ste 209 Jacksonville FL 32217-2103 | |
| (904) 543-6055 | |
| (904) 395-9181 |
| Full Name | |
|---|---|
| Speciality | Social Worker |
| Location | 3733 University Blvd W Ste 209, Jacksonville, Florida |
| Authorized Official Name and Position | Lisa J Rotella (OWNER) |
| Authorized Official Contact | 6103312645 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
6652 Epping Forest Way N Jacksonville FL 32217-2648 Ph: (904) 280-0790 | 3733 University Blvd W Ste 209 Jacksonville FL 32217-2103 Ph: (904) 543-6055 |
| NPI Number | 1770955254 |
|---|---|
| Provider Enumeration Date | 10/23/2015 |
| Last Update Date | 09/17/2021 |
| Certification Date | 09/17/2021 |
| Medicare PECOS PAC ID | 6608161245 |
|---|---|
| Medicare Enrollment ID | O20160822002667 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1770955254 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | SW13084 (Florida) | Primary |
| Provider Name | Lisa Rotella |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1174943815 PECOS PAC ID: 6406141043 Enrollment ID: I20160822002780 |
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