=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184153934
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRODIGAL S D CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2017
-----------------------------------------------------
Last Update Date | 06/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9521 SHELLIE RD STE 13
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32257-6174
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-930-4244
-----------------------------------------------------
Fax | 954-256-8140
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9838 OLD BAYMEADOWS RD # 267
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-8101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-930-4244
-----------------------------------------------------
Fax | 954-256-8140
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | FREDA STEVENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-930-4244
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP1600X
-----------------------------------------------------
Taxonomy Name | Pastoral Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TP2701X
-----------------------------------------------------
Taxonomy Name | Group Psychotherapy Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------