Healthcare Provider Details

I. General information

NPI: 1538608112
Provider Name (Legal Business Name): KALENA SMITH-FULWILEY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2017
Last Update Date: 02/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 NEW BERLIN RD
JACKSONVILLE FL
32218-3827
US

IV. Provider business mailing address

15597 SPOTTED SADDLE CIR
JACKSONVILLE FL
32218-7984
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-0886
  • Fax:
Mailing address:
  • Phone: 904-476-9064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH12125
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberMH12125
License Number StateFL

VIII. Authorized Official

Name: KALENA SMITH-FULWILEY
Title or Position: OWNER
Credential: LMHC
Phone: 904-476-9064