Healthcare Provider Details

I. General information

NPI: 1235886466
Provider Name (Legal Business Name): ALLAY BEHAVIORAL THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 TREE BLVD STE 6
ST AUGUSTINE FL
32084-5719
US

IV. Provider business mailing address

1750 TREE BLVD STE 6
ST AUGUSTINE FL
32084-5719
US

V. Phone/Fax

Practice location:
  • Phone: 904-206-7024
  • Fax: 866-374-7560
Mailing address:
  • Phone: 904-206-7024
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: RYAN WILKERSON
Title or Position: OWNER/MEMBER
Credential: BCBA
Phone: 614-900-2403