Healthcare Provider Details

I. General information

NPI: 1053681205
Provider Name (Legal Business Name): BEADED STAR RECOVERY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2012
Last Update Date: 08/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2380 3RD ST S SUITE 1
JACKSONVILLE BEACH FL
32250-4023
US

IV. Provider business mailing address

2380 3RD ST S SUITE 1
JACKSONVILLE BEACH FL
32250-4023
US

V. Phone/Fax

Practice location:
  • Phone: 904-241-3113
  • Fax: 904-513-9268
Mailing address:
  • Phone: 904-241-3113
  • Fax: 904-513-9268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8334
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND546
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberND546
License Number StateFL

VIII. Authorized Official

Name: MS. MARILYN K DAHL
Title or Position: OWNER
Credential: RD, LD/N, MBA, CEDRD
Phone: 904-241-3113