Healthcare Provider Details

I. General information

NPI: 1184153934
Provider Name (Legal Business Name): PRODIGAL S D CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2017
Last Update Date: 06/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9521 SHELLIE RD STE 13
JACKSONVILLE FL
32257-6174
US

IV. Provider business mailing address

9838 OLD BAYMEADOWS RD # 267
JACKSONVILLE FL
32256-8101
US

V. Phone/Fax

Practice location:
  • Phone: 904-930-4244
  • Fax: 954-256-8140
Mailing address:
  • Phone: 904-930-4244
  • Fax: 954-256-8140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State

VIII. Authorized Official

Name: FREDA STEVENS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 904-930-4244