Healthcare Provider Details

I. General information

NPI: 1629689435
Provider Name (Legal Business Name): MONARCH MENTAL HEALTH ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 09/04/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5393 ROOSEVELT BLVD STE 8
JACKSONVILLE FL
32210-8424
US

IV. Provider business mailing address

5393 ROOSEVELT BLVD STE 8
JACKSONVILLE FL
32210-8424
US

V. Phone/Fax

Practice location:
  • Phone: 480-737-1240
  • Fax:
Mailing address:
  • Phone: 480-737-1240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: REGINA EWING
Title or Position: FOUNDER/CEO
Credential: PA-C
Phone: 480-737-1240