Healthcare Provider Details

I. General information

NPI: 1245086040
Provider Name (Legal Business Name): FOUNDATIONS PEDIATRICS ASSESSMENT AND TREATMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2024
Last Update Date: 04/24/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 LAND GRANT STREET SUITE 3
SAINT AUGUSTINE FL
32092
US

IV. Provider business mailing address

247 ORCHARD LN
SAINT AUGUSTINE FL
32095-0031
US

V. Phone/Fax

Practice location:
  • Phone: 904-370-3420
  • Fax:
Mailing address:
  • Phone: 954-895-3006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JILL DRIEST
Title or Position: OWNER
Credential:
Phone: 904-370-3420