Healthcare Provider Details

I. General information

NPI: 1962096743
Provider Name (Legal Business Name): LVH FL TELEHEALTH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2021
Last Update Date: 06/07/2021
Certification Date: 06/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CORPORATE SQUARE BLVD
JACKSONVILLE FL
32216-1941
US

IV. Provider business mailing address

PO BOX 4458 DEPT 841
HOUSTON TX
77210-4458
US

V. Phone/Fax

Practice location:
  • Phone: 904-515-5086
  • Fax: 866-541-5354
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: LISA LYNNE LASICK
Title or Position: DIRECTOR OF RCM
Credential:
Phone: 954-559-1378