Healthcare Provider Details

I. General information

NPI: 1912469396
Provider Name (Legal Business Name): FAMILY MATTERS OF FLORIDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 WELLS RD STE 203
ORANGE PARK FL
32073-3036
US

IV. Provider business mailing address

165 WELLS RD STE 203
ORANGE PARK FL
32073-3036
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-3522
  • Fax:
Mailing address:
  • Phone: 904-269-3522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: TRACY JOHNSTON
Title or Position: OWNER
Credential: LMHC
Phone: 904-269-3522