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General NPI Number Information
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NPI Number | 1003314790
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Entity Type | Organization
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Legal Business Name | MTB THERAPIST, LLC
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Dates
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Enumeration Date | 01/27/2018
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Last Update Date | 04/22/2025
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Provider Practice Location Address
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Address Line | 6034 CHESTER AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2264
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Country | US
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Telephone | 904-323-2019
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Fax |
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Provider Business Mailing Address
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Address Line | 3452 LIVE OAK HOLLOW DR
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City | ORANGE PARK
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State | FL
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Zip | 32065-2525
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Country | US
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Telephone |
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Fax | 904-323-0469
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Authorized Official
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Title or Position | DIRECTOR
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Name | MERLAND BAKER
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Credential | LMHC
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Telephone | 904-322-2162
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 15468
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 15468
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 15468
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 15468
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License Number State | FL
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