| Ethereal Counseling Center Llc | |
|
10035 Bengal Fox Dr Jacksonville FL 32222-2895 | |
| (904) 515-3326 | |
| Not Available |
| Full Name | Ethereal Counseling Center Llc |
|---|---|
| Speciality | Counselor |
| Location | 10035 Bengal Fox Dr, Jacksonville, Florida |
| Authorized Official Name and Position | Dana Weiss (CREDENTIALING SPECIALIST) |
| Authorized Official Contact | 9047013076 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Ethereal Counseling Center Llc 10035 Bengal Fox Dr Jacksonville FL 32222-2895 Ph: (904) 515-3326 | Ethereal Counseling Center Llc 10035 Bengal Fox Dr Jacksonville FL 32222-2895 Ph: (904) 515-3326 |
| NPI Number | 1164188496 |
|---|---|
| Provider Enumeration Date | 11/10/2021 |
| Last Update Date | 07/24/2023 |
| Certification Date | 07/24/2023 |
| Medicare PECOS PAC ID | 0941658900 |
|---|---|
| Medicare Enrollment ID | O20231130004006 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1164188496 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YM0800X | Counselor - Mental Health | (* (Not Available)) | Primary |
| 106H00000X | Marriage & Family Therapist | (* (Not Available)) | Secondary |
| Provider Name | Yolla N Bailey |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1770051419 PECOS PAC ID: 1850749813 Enrollment ID: I20231130004022 |
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