Healthcare Provider Details

I. General information

NPI: 1306192513
Provider Name (Legal Business Name): FAMILY COUNSELING & PSYCHOLOGICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5422 FIRST COAST HWY STE 119
AMELIA ISLAND FL
32034-5423
US

IV. Provider business mailing address

5422 FIRST COAST HWY STE 119
AMELIA ISLAND FL
32034-5423
US

V. Phone/Fax

Practice location:
  • Phone: 904-432-7617
  • Fax: 904-432-7088
Mailing address:
  • Phone: 904-432-7617
  • Fax: 904-432-7088

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number5460
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5460
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5548
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number5460
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number5548
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number5548
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMH5548
License Number StateFL

VIII. Authorized Official

Name: DR. KENNETH F. JOHNSON
Title or Position: ADMINISTRATOR OF BUSINESS
Credential: DR.
Phone: 386-235-3831