Healthcare Provider Details

I. General information

NPI: 1821433434
Provider Name (Legal Business Name): MICHAEL EDWIN YEAGER LMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 W DUVAL ST
LAKE CITY FL
32055-3899
US

IV. Provider business mailing address

512 W DUVAL ST
LAKE CITY FL
32055-3899
US

V. Phone/Fax

Practice location:
  • Phone: 386-754-9005
  • Fax: 386-754-9017
Mailing address:
  • Phone: 386-754-9005
  • Fax: 386-754-9017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAP4081
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberMH11765
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License NumberMH11765
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH11765
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: