Healthcare Provider Details

I. General information

NPI: 1629564489
Provider Name (Legal Business Name): BEYOND THE COUCH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2018
Last Update Date: 07/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

516 S 10TH ST STE 119
FERNANDINA BEACH FL
32034-3511
US

IV. Provider business mailing address

PO BOX 15905
FERNANDINA BEACH FL
32035-3116
US

V. Phone/Fax

Practice location:
  • Phone: 904-863-6746
  • Fax: 347-412-5958
Mailing address:
  • Phone: 904-863-6746
  • Fax: 347-412-5958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9903
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. JULIE DIANE EBERWEIN
Title or Position: CO-FOUNDER
Credential: PHD., LMHC, CAP
Phone: 904-863-6746