Healthcare Provider Details

I. General information

NPI: 1003099516
Provider Name (Legal Business Name): COUNSELING ASSOCIATES OF PORT ORANGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 S NOVA RD SUITE 5
PORT ORANGE FL
32127-9278
US

IV. Provider business mailing address

3959 S NOVA RD SUITE 5
PORT ORANGE FL
32127-9278
US

V. Phone/Fax

Practice location:
  • Phone: 386-761-2390
  • Fax: 386-761-3256
Mailing address:
  • Phone: 386-761-2390
  • Fax: 386-761-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW3855
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberSW3855
License Number StateFL

VIII. Authorized Official

Name: DR. PATTI K HALL
Title or Position: SECRETARY/TREASURER
Credential: PHD
Phone: 386-761-2390