MEDICARE: THE BODY IMAGE COUNSELING CENTER

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	133V00000X	Registered Dietitian	ND4743	FL
2	1041C0700X	Clinical Social Worker	SW5916	FL

General Provider Information

NPI Number	:	1396257630
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BODY IMAGE COUNSELING CENTER

Provider Business Mailing Address
First Line	:	1545 LANDON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8671
Country	:	US
Telephone Number	:	904-737-3232
Fax Number	:

Provider Business Practice Location Address
First Line	:	1545 LANDON AVE
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-8671
Country	:	US
Telephone Number	:	904-737-3232
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LORI OSACHY
Credential	:	LCSW
Telephone Number	:	904-737-3232

Provider Enumeration Date	:	10/26/2017
Last Update Date	:	10/26/2017

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Directions to “THE BODY IMAGE COUNSELING CENTER ” Practice Location

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