Provider Demographics
NPI:1306192513
Name:FAMILY COUNSELING & PSYCHOLOGICAL SERVICES LLC
Entity type:Organization
Organization Name:FAMILY COUNSELING & PSYCHOLOGICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR OF BUSINESS
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:F
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:386-235-3831
Mailing Address - Street 1:5422 FIRST COAST HWY
Mailing Address - Street 2:STE 119
Mailing Address - City:AMELIA ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32034-5423
Mailing Address - Country:US
Mailing Address - Phone:904-432-7617
Mailing Address - Fax:904-432-7088
Practice Address - Street 1:5422 FIRST COAST HWY
Practice Address - Street 2:STE 119
Practice Address - City:AMELIA ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32034-5423
Practice Address - Country:US
Practice Address - Phone:904-432-7617
Practice Address - Fax:904-432-7088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-25
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH5548251S00000X
FL5548101YM0800X, 103T00000X, 103TE1100X
FL5460101YA0400X, 101YP1600X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & SportsGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty