Healthcare Provider Details

I. General information

NPI: 1437733367
Provider Name (Legal Business Name): HALCYON CREST LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 A1A N STE 310
PONTE VEDRA BEACH FL
32082-8209
US

IV. Provider business mailing address

822 A1A N STE 310
PONTE VEDRA BEACH FL
32082-8209
US

V. Phone/Fax

Practice location:
  • Phone: 904-686-6856
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: LAUREN FRYE
Title or Position: PSYCHOLOGIST
Credential: PHD, BCC
Phone: 904-686-6856