Healthcare Provider Details

I. General information

NPI: 1841337060
Provider Name (Legal Business Name): THERAPY SOURCE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 BEACH BLVD
JACKSONVILLE FL
32207-3704
US

IV. Provider business mailing address

3311 BEACH BLVD
JACKSONVILLE FL
32207-3704
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-1462
  • Fax: 904-396-1199
Mailing address:
  • Phone: 904-396-1462
  • Fax: 904-396-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSAN DIANNE DRISCOLL
Title or Position: PRESIDENT/CEO
Credential:
Phone: 904-396-1462