MEDICARE: BEACHES THERAPY 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	1041C0700X	Clinical Social Worker	11846	FL
2	261QM0850X	Adult Mental Health Clinic/Center	11846	FL
3	261QM0855X	Adolescent and Children Mental Health Clinic/Center	11846	FL
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	11846	FL

General Provider Information

NPI Number	:	1922471721
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACHES THERAPY LLC

Provider Business Mailing Address
First Line	:	1552 ROBERTS DR
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3222
Country	:	US
Telephone Number	:	904-729-2947
Fax Number	:

Provider Business Practice Location Address
First Line	:	1552 ROBERTS DR
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3222
Country	:	US
Telephone Number	:	904-729-2947
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	AUDREY ROACH-SLIVINSKI
Credential	:	LCSW
Telephone Number	:	904-729-2947

Provider Enumeration Date	:	11/03/2015
Last Update Date	:	03/17/2018

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