=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891147120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEECH COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2016
-----------------------------------------------------
Last Update Date | 05/01/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1849 DEAN RD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-4520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-994-8551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1849 DEAN RD
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32216-4520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-994-8551
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MRS. BILLIE ASHLEY BEECH-MAVRANTZAS
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 904-994-8551
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SW13692
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------