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General NPI Number Information
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NPI Number | 1770955254
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Entity Type | Organization
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Legal Business Name | BEACHES BEHAVIORAL HEALTH LLC
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Dates
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Enumeration Date | 10/23/2015
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Last Update Date | 09/17/2021
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Provider Practice Location Address
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Address Line | 3733 UNIVERSITY BLVD W STE 209
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2103
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Country | US
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Telephone | 904-543-6055
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Fax | 904-395-9181
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Provider Business Mailing Address
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Address Line | 6652 EPPING FOREST WAY N
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City | JACKSONVILLE
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State | FL
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Zip | 32217-2648
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Country | US
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Telephone | 904-280-0790
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Fax | 904-395-9181
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Authorized Official
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Title or Position | OWNER
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Name | LISA J ROTELLA
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Credential | LCSW
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Telephone | 610-331-2645
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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 | SW13084
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License Number State | FL
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