Healthcare Provider Details

I. General information

NPI: 1063847465
Provider Name (Legal Business Name): PSI BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3890 DUNN AVE SUITE 1104
JACKSONVILLE FL
32218-6428
US

IV. Provider business mailing address

3890 DUNN AVE SUITE 1104
JACKSONVILLE FL
32218-6428
US

V. Phone/Fax

Practice location:
  • Phone: 904-723-6049
  • Fax:
Mailing address:
  • Phone: 904-723-6049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. RICKY WALLACE
Title or Position: CEO
Credential:
Phone: 904-723-6049