=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265199095
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHINCHILLA COUNSELING AND COACHING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2021
-----------------------------------------------------
Last Update Date | 11/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7643 GATE PKWY # 104-1034
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-3092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-649-2665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7643 GATE PKWY # 104-1034
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32256-3092
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-649-2665
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CRISTINA CHINCHILLA
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 904-649-2671
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------