=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407651276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ARC OF THE ST. JOHNS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2025
-----------------------------------------------------
Last Update Date | 02/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2109 ARC DR
-----------------------------------------------------
City | ST AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-0512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-7249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2101 ARC DR
-----------------------------------------------------
City | SAINT AUGUSTINE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32084-0512
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-824-7249
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF FINANCE
-----------------------------------------------------
Name | JUSTIN BREIDENSTEIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 904-824-7249
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 172A00000X
-----------------------------------------------------
Taxonomy Name | Driver
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2355S0801X
-----------------------------------------------------
Taxonomy Name | Speech-Language Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------