MEDICARE: FITMIND THERAPEUTICS ADVANCED BEHAVIORAL HEALTH

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	261QP2300X	Primary Care Clinic/Center
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1811738768
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FITMIND THERAPEUTICS ADVANCED BEHAVIORAL HEALTH

Provider Business Mailing Address
First Line	:	12574 FLAGLER CENTER BLVD STE 101
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2615
Country	:	US
Telephone Number	:	315-269-0847
Fax Number	:

Provider Business Practice Location Address
First Line	:	12574 FLAGLER CENTER BLVD STE 101
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-2615
Country	:	US
Telephone Number	:	315-269-0847
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	VICTORIA KOZEL
Credential	:	DNP, PMHNP-BC, FNP
Telephone Number	:	904-679-5439

Provider Enumeration Date	:	06/04/2024
Last Update Date	:	09/10/2024

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