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General NPI Number Information
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NPI Number | 1710589205
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Entity Type | Organization
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Legal Business Name | SANKOFA BEHAVIORAL HEALTH SERVICES LLC
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Dates
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Enumeration Date | 11/10/2020
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Last Update Date | 11/10/2020
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Provider Practice Location Address
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Address Line | 5379 LENOX AVE
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City | JACKSONVILLE
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State | FL
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Zip | 32205-4737
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Country | US
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Telephone | 904-891-6614
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Fax | 904-512-6614
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Provider Business Mailing Address
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Address Line | PO BOX 8056
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City | JACKSONVILLE
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State | FL
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Zip | 32239-0056
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Country | US
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Telephone | 904-891-6614
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Fax | 904-512-6614
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Authorized Official
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Title or Position | LMHC
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Name | DR. MIA R WILSON
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Credential | ED.D
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Telephone | 904-891-6614
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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