MEDICARE: CONNECT TO COUNSELING, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	101YP2500X	Professional Counselor
3	1041C0700X	Clinical Social Worker
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1548856933
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECT TO COUNSELING, LLC

Provider Business Mailing Address
First Line	:	1225 W BEAVER ST STE 120
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-1415
Country	:	US
Telephone Number	:	904-648-6200
Fax Number	:	904-648-6300

Provider Business Practice Location Address
First Line	:	1225 W BEAVER ST STE 120
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32204-1415
Country	:	US
Telephone Number	:	904-648-6200
Fax Number	:	904-648-6300

Authorized Official
Title or Position	:	OWNER
Name	:	CHARITA BRYANT
Credential	:
Telephone Number	:	904-648-6200

Provider Enumeration Date	:	12/19/2020
Last Update Date	:	12/19/2020

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