Healthcare Provider Details

I. General information

NPI: 1396503157
Provider Name (Legal Business Name): RESTORE COMMUNITY COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

96 MASTERS DR
SAINT AUGUSTINE FL
32084-3169
US

IV. Provider business mailing address

96 MASTERS DR
SAINT AUGUSTINE FL
32084-3169
US

V. Phone/Fax

Practice location:
  • Phone: 904-670-1595
  • Fax:
Mailing address:
  • Phone: 904-670-1595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GABRIELLE M COMPTON
Title or Position: PRESIDENT
Credential:
Phone: 904-670-1595