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General NPI Number Information
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NPI Number | 1285144949
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Entity Type | Organization
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Legal Business Name | CROSSROADS THERAPY, LLC
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Dates
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Enumeration Date | 10/09/2017
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Last Update Date | 10/09/2017
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Provider Practice Location Address
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Address Line | 408 4TH ST N
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City | JACKSONVILLE BEACH
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State | FL
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Zip | 32250-5620
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Country | US
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Telephone | 904-853-7780
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Fax |
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Provider Business Mailing Address
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Address Line | 333 9TH ST
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City | ATLANTIC BEACH
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State | FL
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Zip | 32233-5437
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | KELLY SUZANNE GORDON
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Credential | LCSW
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Telephone | 904-853-7780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 14099
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License Number State | FL
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