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General NPI Number Information
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NPI Number | 1053681205
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Entity Type | Organization
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Legal Business Name | BEADED STAR RECOVERY,LLC
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Dates
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Enumeration Date | 01/05/2012
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Last Update Date | 08/07/2015
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Provider Practice Location Address
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Address Line | 2380 3RD ST S SUITE 1
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250-4023
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Country | US
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Telephone | 904-241-3113
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Fax | 904-513-9268
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Provider Business Mailing Address
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Address Line | 2380 3RD ST S SUITE 1
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250-4023
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Country | US
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Telephone | 904-241-3113
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Fax | 904-513-9268
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Authorized Official
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Title or Position | OWNER
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Name | MS. MARILYN K DAHL
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Credential | RD, LD/N, MBA, CEDRD
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Telephone | 904-241-3113
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH8334
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | ND546
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number | ND546
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License Number State | FL
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