Healthcare Provider Details

I. General information

NPI: 1174761118
Provider Name (Legal Business Name): COUNSELING ASSOCIATES CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2009
Last Update Date: 04/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 A1A BEACH BLVD UNIT #5
ST AUGUSTINE FL
32080-6776
US

IV. Provider business mailing address

890 A1A BEACH BLVD UNIT #5
ST AUGUSTINE FL
32080-6776
US

V. Phone/Fax

Practice location:
  • Phone: 904-471-5623
  • Fax: 904-471-7545
Mailing address:
  • Phone: 904-471-5623
  • Fax: 904-471-7545

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMMOTHY NELSON TILLOTSON
Title or Position: OWNER
Credential:
Phone: 904-471-5623