=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033836978
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLOTTE ELLEGOOD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2022
-----------------------------------------------------
Last Update Date | 02/22/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7775 BAYMEADOWS WAY STE 200
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-7531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-831-3974
-----------------------------------------------------
Fax | 855-857-1695
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6349 FAULKNER DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32244-2488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-285-1064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | RBT-22-240593
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------