Healthcare Provider Details

I. General information

NPI: 1801106539
Provider Name (Legal Business Name): ROBIN C STALEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ROBIN MICHELLE CUEVAS

II. Dates (important events)

Enumeration Date: 10/15/2010
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5633 CLIFTON AVE
JACKSONVILLE FL
32211-6901
US

IV. Provider business mailing address

910 N JEFFERSON ST
JACKSONVILLE FL
32209-6810
US

V. Phone/Fax

Practice location:
  • Phone: 904-503-0131
  • Fax:
Mailing address:
  • Phone: 904-360-7022
  • Fax: 904-798-4544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH18706
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: