=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225511280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KELLY SAYERS COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2018
-----------------------------------------------------
Last Update Date | 09/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1890 S 14TH ST STE 110
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-4718
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-556-7242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 861417 N HAMPTON CLUB WAY
-----------------------------------------------------
City | FERNANDINA BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32034-8705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-709-4698
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KELLY SAYERS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 904-601-6107
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------