MEDICARE: FAMILY MATTERS OF FLORIDA 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	252Y00000X	Early Intervention Provider Agency
2	222Q00000X	Developmental Therapist

General Provider Information

NPI Number	:	1912469396
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAMILY MATTERS OF FLORIDA LLC

Provider Business Mailing Address
First Line	:	165 WELLS RD STE 203
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-3036
Country	:	US
Telephone Number	:	904-269-3522
Fax Number	:

Provider Business Practice Location Address
First Line	:	165 WELLS RD STE 203
Second Line	:
City	:	ORANGE PARK
State	:	FL
Zip	:	32073-3036
Country	:	US
Telephone Number	:	904-269-3522
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	TRACY JOHNSTON
Credential	:	LMHC
Telephone Number	:	904-269-3522

Provider Enumeration Date	:	04/03/2019
Last Update Date	:	04/03/2019

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