Provider Demographics
NPI:1386470334
Name:SOARES, ILLYANNA (RMHCI)
Entity type:Individual
Prefix:
First Name:ILLYANNA
Middle Name:
Last Name:SOARES
Suffix:
Gender:F
Credentials:RMHCI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7385 PARK VILLAGE DR APT 6412
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8030
Mailing Address - Country:US
Mailing Address - Phone:703-774-7171
Mailing Address - Fax:
Practice Address - Street 1:6100 GREENLAND RD STE 903
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-7450
Practice Address - Country:US
Practice Address - Phone:407-594-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26521101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health