MEDICARE: LAUREL OAKS COUNSELING 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	MH6317	FL
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1649718974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LAUREL OAKS COUNSELING LLC

Provider Business Mailing Address
First Line	:	226 N NOVA RD # 148
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5124
Country	:	US
Telephone Number	:	386-255-0044
Fax Number	:

Provider Business Practice Location Address
First Line	:	444 SEABREEZE BLVD
Second Line	:	SUITE 730
City	:	DAYTONA BEACH
State	:	FL
Zip	:	32118-3958
Country	:	US
Telephone Number	:	386-255-0044
Fax Number	:	385-255-0045

Authorized Official
Title or Position	:	OWNER
Name	:	AMANDA NIXON
Credential	:	LCSW
Telephone Number	:	386-255-0044

Provider Enumeration Date	:	02/07/2017
Last Update Date	:	04/29/2020

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