Provider Demographics
NPI:1962697441
Name:SANTA ROSA COUNSELING CENTER LLC
Entity type:Organization
Organization Name:SANTA ROSA COUNSELING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:ALESIA
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT, LMHC
Authorized Official - Phone:850-626-7779
Mailing Address - Street 1:5642 JONES ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-2304
Mailing Address - Country:US
Mailing Address - Phone:850-626-7779
Mailing Address - Fax:850-626-7171
Practice Address - Street 1:5642 JONES ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-2304
Practice Address - Country:US
Practice Address - Phone:850-626-7779
Practice Address - Fax:850-626-7171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH8971101YM0800X
101YM0800X
FLMT2297106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103671100Medicaid