MEDICARE: PSI BEHAVIORAL HEALTH, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)		FL
2	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154762284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PSI BEHAVIORAL HEALTH, LLC

Provider Business Mailing Address
First Line	:	3450 DUNN AVE STE 201
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-6427
Country	:	US
Telephone Number	:	904-723-6049
Fax Number	:

Provider Business Practice Location Address
First Line	:	3450 DUNN AVE STE 201
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-6427
Country	:	US
Telephone Number	:	904-723-6049
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RICKY WALLACE
Credential	:
Telephone Number	:	904-534-4937

Provider Enumeration Date	:	07/17/2013
Last Update Date	:	11/17/2025

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