Healthcare Provider Details

I. General information

NPI: 1558798405
Provider Name (Legal Business Name): NORTHEAST FLORIDA PSYCHIATRIC ASSOCIATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2013
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 DUNLAWTON AVE STE 1
PORT ORANGE FL
32127-4931
US

IV. Provider business mailing address

804 DUNLAWTON AVE STE 1
PORT ORANGE FL
32127-4931
US

V. Phone/Fax

Practice location:
  • Phone: 386-767-8584
  • Fax: 386-767-8536
Mailing address:
  • Phone: 386-767-8584
  • Fax: 386-767-8536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME73316
License Number StateFL

VIII. Authorized Official

Name: GARY FRICK
Title or Position: PROVIDER
Credential: MD
Phone: 386-767-8584