MEDICARE: SOUTHSIDE COUNSELING BIOFEEDBACK & STRESS MANAGEMENT CENTER, INC

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	MH 1539	FL

General Provider Information

NPI Number	:	1760932529
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHSIDE COUNSELING BIOFEEDBACK & STRESS MANAGEMENT CENTER, INC

Provider Business Mailing Address
First Line	:	4943 BEACH BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4802
Country	:	US
Telephone Number	:	904-396-9144
Fax Number	:

Provider Business Practice Location Address
First Line	:	4943 BEACH BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32207-4802
Country	:	US
Telephone Number	:	904-396-9144
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE
Name	:	MRS. THERESA G. STANFORD
Credential	:
Telephone Number	:	904-396-9144

Provider Enumeration Date	:	10/05/2016
Last Update Date	:	10/05/2016

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