MEDICARE: FIRST COAST EVALUATION CENTER, 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	103TS0200X	School Psychologist

General Provider Information

NPI Number	:	1164245965
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST COAST EVALUATION CENTER, LLC

Provider Business Mailing Address
First Line	:	1492 LANDAU RD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32225-8275
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3101 SAWGRASS VILLAGE CIR
Second Line	:
City	:	PONTE VEDRA BEACH
State	:	FL
Zip	:	32082-5032
Country	:	US
Telephone Number	:	904-889-0089
Fax Number	:

Authorized Official
Title or Position	:	CO-FOUNDER
Name	:	ARIANA GRAY
Credential	:	ED.S., NCSP
Telephone Number	:	904-274-1119

Provider Enumeration Date	:	11/01/2024
Last Update Date	:	11/01/2024

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