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General NPI Number Information
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NPI Number | 1952997900
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Entity Type | Organization
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Legal Business Name | KEYSTONE SUPPORT SERVICES LLC
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Dates
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Enumeration Date | 12/14/2020
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Last Update Date | 12/15/2020
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Provider Practice Location Address
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Address Line | 10135 GATE PKWY N APT 1516
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City | JACKSONVILLE
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State | FL
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Zip | 32246-8267
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Country | US
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Telephone | 954-224-8216
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Fax |
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Provider Business Mailing Address
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Address Line | 10135 GATE PKWY N APT 1516
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City | JACKSONVILLE
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State | FL
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Zip | 32246-8267
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Country | US
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Telephone | 954-224-8216
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Fax |
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Authorized Official
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Title or Position | OWNER/ OPERATOR
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Name | REGINA SHERMAN
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Credential |
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Telephone | 352-658-1016
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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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 | 320900000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
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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 | 261QD1600X
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Taxonomy Name | Developmental Disabilities Clinic/Center
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License Number |
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License Number State |
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