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	251S00000X	Community/Behavioral Health Agency	SW5916	FL

General Provider Information

NPI Number	:	1922247501
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	:	904-396-4505

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	:	904-396-4505

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. LORI BETH OSACHY
Credential	:	MSS
Telephone Number	:	904-737-3232

Provider Enumeration Date	:	02/05/2009
Last Update Date	:	02/05/2009

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