Healthcare Provider Details

I. General information

NPI: 1568964039
Provider Name (Legal Business Name): KEEP A KID ON TRACK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

623 PINE HILL ROAD
ORLANDO FL
32808
US

IV. Provider business mailing address

2425 FLOWER CORAL DR. SUITE 300
ORLANDO FL
32808
US

V. Phone/Fax

Practice location:
  • Phone: 305-788-6269
  • Fax:
Mailing address:
  • Phone: 305-788-6269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM M CLARK JR.
Title or Position: PRESIDENT
Credential:
Phone: 305-788-6269