=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194450676
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURPLE MOON SERVICE CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2022
-----------------------------------------------------
Last Update Date | 07/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 931 CASSAT AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32205-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-233-1019
-----------------------------------------------------
Fax | 904-369-4666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 931 CASSAT AVE
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32205-4857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-233-1019
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR -OWNER
-----------------------------------------------------
Name | MS. VALJEANNE R CASTER
-----------------------------------------------------
Credential | LMHC, MAC, CAMSII,
-----------------------------------------------------
Telephone | 904-233-1019
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------