Healthcare Provider Details

I. General information

NPI: 1528823200
Provider Name (Legal Business Name): EAW PSYCHOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2024
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14286 BEACH BLVD STE 19177
JACKSONVILLE FL
32250-1561
US

IV. Provider business mailing address

14286 BEACH BLVD STE 19177
JACKSONVILLE FL
32250-1561
US

V. Phone/Fax

Practice location:
  • Phone: 904-497-2423
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State

VIII. Authorized Official

Name: ELLEN WILLIAMS
Title or Position: PRESIDENT
Credential: PHD
Phone: 904-497-2423