=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619032166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST COAST FAMILY COUNSELING, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/26/2006
-----------------------------------------------------
Last Update Date | 11/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1718 KINGSLEY AVE STE 21
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-567-6100
-----------------------------------------------------
Fax | 904-602-8055
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9445
-----------------------------------------------------
City | FLEMMING ISLAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-567-6100
-----------------------------------------------------
Fax | 904-602-8055
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MICHAEL G. MCCLENDON
-----------------------------------------------------
Credential | LMHC-MA
-----------------------------------------------------
Telephone | 904-567-6100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 5472
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------