Healthcare Provider Details

I. General information

NPI: 1073497608
Provider Name (Legal Business Name): EDUCATION TRANSFORMATION ENTERPRISES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2025
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

767 BLANDING BLVD STE 110B
ORANGE PARK FL
32065-5788
US

IV. Provider business mailing address

767 BLANDING BLVD STE 110B
ORANGE PARK FL
32065-5788
US

V. Phone/Fax

Practice location:
  • Phone: 904-539-8300
  • Fax:
Mailing address:
  • Phone: 904-539-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. KRISTAL TODD
Title or Position: EXECUTIVE DIRECTOR
Credential: FLDOE TEACHER
Phone: 904-539-8300