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General NPI Number Information
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NPI Number | 1457755530
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Entity Type | Organization
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Legal Business Name | HEALING HEARTS THERAPY LLC
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Dates
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Enumeration Date | 10/17/2014
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Last Update Date | 10/17/2014
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Provider Practice Location Address
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Address Line | 13400 SUTTON PARK DR S SUITE 1001-4/5
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City | JACKSONVILLE
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State | FL
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Zip | 32224-0236
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Country | US
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Telephone | 904-318-6109
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Fax |
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Provider Business Mailing Address
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Address Line | 352 VALE DR
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City | ST AUGUSTINE
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State | FL
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Zip | 32095-4835
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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 | OWNER
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Name | STEPHANIE VAVILALA
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Credential |
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Telephone | 904-318-6109
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MH6901
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License Number State | FL
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