=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609366558
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID TOLBERT LMHC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2018
-----------------------------------------------------
Last Update Date | 05/16/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 302 3RD ST STE 1
-----------------------------------------------------
City | NEPTUNE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32266-5139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-465-4503
-----------------------------------------------------
Fax | 904-212-1117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 436 SEAGATE AVE
-----------------------------------------------------
City | NEPTUNE BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32266-4871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-465-4503
-----------------------------------------------------
Fax | 904-212-1117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DAVID TOLBERT
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 904-465-4503
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | MH8992
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------