Healthcare Provider Details

I. General information

NPI: 1093572521
Provider Name (Legal Business Name): CHARLOTTE E BLANDING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CENTURY 21 DR STE 201
JACKSONVILLE FL
32216-9295
US

IV. Provider business mailing address

103 CENTURY 21 DR STE 201
JACKSONVILLE FL
32216-9295
US

V. Phone/Fax

Practice location:
  • Phone: 904-240-8633
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PROF. CHARLOTTE E BLANDING
Title or Position: LICENSED MENTAL HEALTH COUNSELOR
Credential: ED.D
Phone: 904-240-8633