Basic Information
| Provider Information | |||||||||
| NPI: | 1912575655 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILD GUIDANCE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5776 SAINT AUGUSTINE RD | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044006739 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3292 COUNTY ROAD 220 | ||||||||
| Address2: | |||||||||
| City: | MIDDLEBURG | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320684357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044484700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2021 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | OBERLANDER | ||||||||
| AuthorizedOfficialFirstName: | BETH | ||||||||
| AuthorizedOfficialMiddleName: | ELLEN | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF CLINICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9044006739 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 060404620 | 05 | FL | MEDICAID |