MEDICARE: GOOLSBYS CLINICAL SERVICES, 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	101YM0800X	Mental Health Counselor	MH12309	FL

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	:	1174027130
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOOLSBYS CLINICAL SERVICES, LLC

Provider Business Mailing Address
First Line	:	9233 REDTAIL DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-2811
Country	:	US
Telephone Number	:	904-338-2998
Fax Number	:	844-250-8734

Provider Business Practice Location Address
First Line	:	2720 PARK ST STE 202
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32205-7645
Country	:	US
Telephone Number	:	904-338-2998
Fax Number	:	844-250-8734

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN GOOLSBY
Credential	:
Telephone Number	:	904-338-2998

Provider Enumeration Date	:	03/22/2018
Last Update Date	:	03/22/2018

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