Healthcare Provider Details

I. General information

NPI: 1407474943
Provider Name (Legal Business Name): EMDR TRAUMA THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2020
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4609 US HIGHWAY 17 STE 1
FLEMING ISLAND FL
32003-4818
US

IV. Provider business mailing address

4609 US HIGHWAY 17 STE 1
FLEMING ISLAND FL
32003-4818
US

V. Phone/Fax

Practice location:
  • Phone: 904-375-2353
  • Fax: 904-375-2349
Mailing address:
  • Phone: 904-375-2353
  • Fax: 904-375-2349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. JEANNIE L MITCHELL
Title or Position: PRINCIPLE/OWNER
Credential: LMHC
Phone: 904-375-2353