Healthcare Provider Details

I. General information

NPI: 1548159395
Provider Name (Legal Business Name): EASTERN ARTISTS EXPRESSIVE THERAPIES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/28/2025
Last Update Date: 06/28/2025
Certification Date: 06/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10416 NW 148TH PL
ALACHUA FL
32615-5725
US

IV. Provider business mailing address

10416 NW 148TH PL
ALACHUA FL
32615-5725
US

V. Phone/Fax

Practice location:
  • Phone: 561-617-0600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: TIM COHEN
Title or Position: THERAPIST
Credential:
Phone: 914-552-0018