Basic Information
| Provider Information | |||||||||
| NPI: | 1962697441 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SANTA ROSA COUNSELING CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5642 JONES ST | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325702304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506267779 | ||||||||
| FaxNumber: | 8506267171 | ||||||||
| Practice Location | |||||||||
| Address1: | 5642 JONES ST | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325702304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506267779 | ||||||||
| FaxNumber: | 8506267171 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | WILLIS | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | ALESIA | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 8506267779 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMFT, LMHC | ||||||||
| NPICertificationDate: | 06/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | MH8971 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | MT2297 | FL | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 103671100 | 05 | FL | MEDICAID |