Healthcare Provider Details

I. General information

NPI: 1154762284
Provider Name (Legal Business Name): PSI BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 DUNN AVE STE 201
JACKSONVILLE FL
32218-6427
US

IV. Provider business mailing address

3450 DUNN AVE STE 201
JACKSONVILLE FL
32218-6427
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 TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: RICKY WALLACE
Title or Position: CEO
Credential:
Phone: 904-534-4937