MEDICARE: SSW COUNSELING, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1346804051
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSW COUNSELING, PLLC

Provider Business Mailing Address
First Line	:	9617 WATERSHED DR E
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32220-0906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2820 GIBSON RD STE A
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4804
Country	:	US
Telephone Number	:	850-496-0909
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHANTHALITTA WALLACE
Credential	:	LMHC
Telephone Number	:	850-496-0909

Provider Enumeration Date	:	04/29/2019
Last Update Date	:	04/29/2019

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