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General NPI Number Information
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NPI Number | 1770297160
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Entity Type | Organization
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Legal Business Name | KMG BEHAVIORAL HEALTH SERVICES LLC
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Dates
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Enumeration Date | 01/10/2023
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Last Update Date | 10/26/2023
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Provider Practice Location Address
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Address Line | 15165 MICHELANGELO BLVD APT 207
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City | DELRAY BEACH
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State | FL
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Zip | 33446-6026
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Country | US
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Telephone | 561-927-9442
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Fax |
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Provider Business Mailing Address
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Address Line | 1601-1 N MAIN ST UNIT 3159
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City | JACKSONVILLE
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State | FL
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Zip | 32206-7707
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Country | US
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Telephone | 561-927-9442
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. TRUDI JUSTICE
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Credential |
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Telephone | 561-927-9442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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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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Taxonomy #3
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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 #4
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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