Basic Information
| Provider Information | |||||||||
| NPI: | 1942465182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHILD GUIDANCE CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1100 CESERY BLVD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322115612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9047453070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5776 SAINT AUGUSTINE RD | ||||||||
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| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044484700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2008 | ||||||||
| LastUpdateDate: | 07/28/2008 | ||||||||
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| AuthorizedOfficialLastName: | PARKER | ||||||||
| AuthorizedOfficialFirstName: | GUY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9044484700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 060404601 | 05 | FL | MEDICAID |