Healthcare Provider Details

I. General information

NPI: 1467003079
Provider Name (Legal Business Name): PHASES OF HEALING, COUNSELING AND THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2019
Last Update Date: 06/02/2021
Certification Date: 06/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 PASEO REYES DR
SAINT AUGUSTINE FL
32095-8462
US

IV. Provider business mailing address

4435 COASTAL HWY
SAINT AUGUSTINE FL
32084-1304
US

V. Phone/Fax

Practice location:
  • Phone: 904-347-0843
  • Fax:
Mailing address:
  • Phone: 904-347-0843
  • Fax:

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

VIII. Authorized Official

Name: MRS. ANGELA MARIE FUSCO
Title or Position: MANAGER
Credential: LMHC
Phone: 904-347-0843