MEDICARE: COUNSELING ASSOCIATES CLINIC

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1174761118
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COUNSELING ASSOCIATES CLINIC

Provider Business Mailing Address
First Line	:	890 A1A BEACH BLVD
Second Line	:	UNIT #5
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32080-6776
Country	:	US
Telephone Number	:	904-471-5623
Fax Number	:	904-471-7545

Provider Business Practice Location Address
First Line	:	890 A1A BEACH BLVD
Second Line	:	UNIT #5
City	:	ST AUGUSTINE
State	:	FL
Zip	:	32080-6776
Country	:	US
Telephone Number	:	904-471-5623
Fax Number	:	904-471-7545

Authorized Official
Title or Position	:	OWNER
Name	:	MR. TIMMOTHY NELSON TILLOTSON
Credential	:
Telephone Number	:	904-471-5623

Provider Enumeration Date	:	01/29/2009
Last Update Date	:	04/15/2009

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