=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154118081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPLETE PSYCHIATRIC CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2025
-----------------------------------------------------
Last Update Date | 06/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 910 S 8TH ST UNIT 301
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-3744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-604-9855
-----------------------------------------------------
Fax | 904-604-9856
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 910 S 8TH ST UNIT 301
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-3744
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-604-9855
-----------------------------------------------------
Fax | 904-604-9856
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PMHNP-BC
-----------------------------------------------------
Name | CASEY GOSS
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 904-604-9855
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------