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General NPI Number Information
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NPI Number | 1154918209
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Entity Type | Organization
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Legal Business Name | THERALOGY, LLC
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Dates
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Enumeration Date | 12/23/2020
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Last Update Date | 12/23/2020
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Provider Practice Location Address
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Address Line | 4300 MARSH LANDING BLVD SUITE 204
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250
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Country | US
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Telephone | 904-515-2050
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Fax |
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Provider Business Mailing Address
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Address Line | 1015 ATLANTIC BLVD STE 161
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City | ATLANTIC BEACH
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State | FL
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Zip | 32233-3313
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Country | US
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Telephone | 904-515-2370
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Fax |
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Authorized Official
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Title or Position | MGR
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Name | CHRISTINE ELLIS
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Credential | LMHC
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Telephone | 904-515-2370
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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 |
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License Number State |
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