=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659745107
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PSYCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2015
-----------------------------------------------------
Last Update Date | 02/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 151 MARY ESTHER BLVD SUITE 307-A
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-362-7400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 151 MARY ESTHER BLVD SUITE 307-A
-----------------------------------------------------
City | MARY ESTHER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32569-1972
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-362-7400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. CARLISE CHERILYN DOWNIE
-----------------------------------------------------
Credential | LCSW, CAP
-----------------------------------------------------
Telephone | 850-362-7400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW 11734
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------