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General NPI Number Information
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NPI Number | 1124304167
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Entity Type | Organization
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Legal Business Name | SOUTHSIDE COUNSELLING CENTER LLC
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Dates
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Enumeration Date | 10/21/2011
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Last Update Date | 03/14/2012
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Provider Practice Location Address
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Address Line | 3681 CAROL ANN LN
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City | JACKSONVILLE
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State | FL
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Zip | 32223-7394
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Country | US
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Telephone | 904-316-3365
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Fax | 904-292-2409
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Provider Business Mailing Address
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Address Line | 2950 HALCYON LN
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City | JACKSONVILLE
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State | FL
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Zip | 32223-6689
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Country | US
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Telephone | 904-316-3365
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Fax | 904-292-2409
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Authorized Official
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Title or Position | OWNER
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Name | MS. CARMELLA GARDNER
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Credential | LMHC
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Telephone | 904-316-3365
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | MH8370
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License Number State | FL
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