Healthcare Provider Details

I. General information

NPI: 1700445350
Provider Name (Legal Business Name): CLEETHERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 PALM COAST PKWY SW UNIT 4
PALM COAST FL
32137-4768
US

IV. Provider business mailing address

395 PALM COAST PKWY SW UNIT 4
PALM COAST FL
32137-4768
US

V. Phone/Fax

Practice location:
  • Phone: 904-512-0018
  • Fax: 904-990-1680
Mailing address:
  • Phone: 904-512-0018
  • Fax: 904-990-1680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA LEE
Title or Position: MANAGER
Credential: LCSW
Phone: 706-587-0934