=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396354858
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HANCOCK-SMITH PEDIATRIC & BEHAVIORAL HEALTH, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2020
-----------------------------------------------------
Last Update Date | 08/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13900 TECH CITY CIR STE 408
-----------------------------------------------------
City | ALACHUA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32615-6090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-518-6006
-----------------------------------------------------
Fax | 386-518-6024
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 305
-----------------------------------------------------
City | ALACHUA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32616-0305
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-518-6006
-----------------------------------------------------
Fax | 385-518-6024
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER & LICENSED PSYCHOLOGIST
-----------------------------------------------------
Name | DR. ANYALIESE DOMINIQUE HANCOCK-SMITH
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 386-518-6006
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------