Provider Demographics
NPI:1457190126
Name:LUMOS MENTAL HEALTH, PLLC
Entity type:Organization
Organization Name:LUMOS MENTAL HEALTH, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:MARGARITA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-322-1232
Mailing Address - Street 1:7643 GATE PKWY STE 104-1381
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3092
Mailing Address - Country:US
Mailing Address - Phone:904-906-6754
Mailing Address - Fax:
Practice Address - Street 1:10151 DEERWOOD PARK BLVD BLDG 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0566
Practice Address - Country:US
Practice Address - Phone:904-906-6754
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1588160303OtherMY INDIVIDUAL NPI