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General NPI Number Information
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NPI Number | 1396257630
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Entity Type | Organization
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Legal Business Name | THE BODY IMAGE COUNSELING CENTER
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Dates
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Enumeration Date | 10/26/2017
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Last Update Date | 10/26/2017
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Provider Practice Location Address
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Address Line | 1545 LANDON AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8671
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Country | US
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Telephone | 904-737-3232
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Fax |
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Provider Business Mailing Address
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Address Line | 1545 LANDON AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32207-8671
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Country | US
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Telephone | 904-737-3232
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | LORI OSACHY
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Credential | LCSW
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Telephone | 904-737-3232
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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 | SW5916
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License Number State | FL
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Taxonomy #2
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Taxonomy Code | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number | ND4743
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License Number State | FL
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