Healthcare Provider Details

I. General information

NPI: 1700596863
Provider Name (Legal Business Name): RESILIENCY WELL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4519 WOODBINE RD
PACE FL
32571-8706
US

IV. Provider business mailing address

4519 WOODBINE RD
PACE FL
32571-8706
US

V. Phone/Fax

Practice location:
  • Phone: 850-778-3747
  • Fax:
Mailing address:
  • Phone: 850-778-3747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: JENNA VAUGHN
Title or Position: THERAPIST/ OWNER
Credential: LMHC
Phone: 850-778-3747