Healthcare Provider Details

I. General information

NPI: 1780327635
Provider Name (Legal Business Name): NORTHEAST FLORIDA EQUESTRIAN SOCIETY/H.O.R.S.E. THERAPIES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 07/06/2022
Certification Date: 07/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13611 NORMANDY BLVD
JACKSONVILLE FL
32221-2409
US

IV. Provider business mailing address

13611 NORMANDY BLVD
JACKSONVILLE FL
32221-2409
US

V. Phone/Fax

Practice location:
  • Phone: 904-576-7491
  • Fax:
Mailing address:
  • Phone: 904-576-7491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TM1800X
TaxonomyIntellectual & Developmental Disabilities Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA SYKES
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 904-576-7491