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General NPI Number Information
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NPI Number | 1407478613
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Entity Type | Organization
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Legal Business Name | MARA'S LIGHTHOUSE COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 05/11/2020
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Last Update Date | 11/18/2025
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Provider Practice Location Address
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Address Line | 12086 FORT CAROLINE RD STE 201
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City | JACKSONVILLE
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State | FL
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Zip | 32225-2689
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Country | US
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Telephone | 904-990-8105
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Fax | 904-562-3359
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Provider Business Mailing Address
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Address Line | 12086 FORT CAROLINE RD STE 201
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City | JACKSONVILLE
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State | FL
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Zip | 32225-2689
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Country | US
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Telephone | 904-990-8105
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Fax | 904-562-3359
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ALEX DE GUZMAN
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Credential |
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Telephone | 904-990-8105
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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 |
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License Number State |
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