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General NPI Number Information
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NPI Number | 1669710273
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Entity Type | Organization
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Legal Business Name | SPRUCE CREEK MENTAL HEALTH SERVICES, LLC
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Dates
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Enumeration Date | 01/17/2013
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Last Update Date | 02/01/2013
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Provider Practice Location Address
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Address Line | 1690 DUNLAWTON AVE SUITE 125
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City | PORT ORANGE
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State | FL
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Zip | 32127-8979
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Country | US
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Telephone | 386-681-8639
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Fax | 386-310-3992
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Provider Business Mailing Address
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Address Line | 6112 PALMAS DR
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City | PORT ORANGE
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State | FL
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Zip | 32127-6751
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Country | US
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Telephone | 386-681-8639
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Fax | 386-310-3992
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Authorized Official
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Title or Position | OWNER
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Name | MR. EDWARD C KING
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Credential | LCSW
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Telephone | 386-681-8639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | SW10520
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License Number State | FL
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