=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538608112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KALENA SMITH-FULWILEY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2017
-----------------------------------------------------
Last Update Date | 02/16/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 422 NEW BERLIN RD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-3827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-269-0886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15597 SPOTTED SADDLE CIR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-7984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-476-9064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KALENA SMITH-FULWILEY
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 904-476-9064
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | MH12125
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MH12125
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------