Healthcare Provider Details

I. General information

NPI: 1356137699
Provider Name (Legal Business Name): JACQUELINE M RITA LMHC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2025
Last Update Date: 05/30/2025
Certification Date: 05/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E INTERNATIONAL SPEEDWAY BLVD STE 107
DAYTONA BEACH FL
32118-4662
US

IV. Provider business mailing address

1225 RUTHBERN RD
DAYTONA BEACH FL
32114-5961
US

V. Phone/Fax

Practice location:
  • Phone: 401-486-6081
  • Fax: 386-401-2414
Mailing address:
  • Phone: 401-486-6081
  • Fax: 386-401-2414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE M RITA
Title or Position: OWNER/PROVIDER
Credential: LMHC
Phone: 401-486-6081