| Spruce Creek Mental Health Services, Llc | |
|
1690 Dunlawton Ave Suite 125 Port Orange FL 32127-8979 | |
| (386) 681-8639 | |
| (386) 310-3992 |
| Full Name | Spruce Creek Mental Health Services, Llc |
|---|---|
| Speciality | Social Worker |
| Location | 1690 Dunlawton Ave, Port Orange, Florida |
| Authorized Official Name and Position | Edward C King (OWNER) |
| Authorized Official Contact | 3866818639 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Spruce Creek Mental Health Services, Llc 6112 Palmas Dr Port Orange FL 32127-6751 Ph: (386) 681-8639 | Spruce Creek Mental Health Services, Llc 1690 Dunlawton Ave Suite 125 Port Orange FL 32127-8979 Ph: (386) 681-8639 |
| NPI Number | 1669710273 |
|---|---|
| Provider Enumeration Date | 01/17/2013 |
| Last Update Date | 02/01/2013 |
| Medicare PECOS PAC ID | 6507166006 |
|---|---|
| Medicare Enrollment ID | O20151207001342 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1669710273 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1041C0700X | Social Worker - Clinical | SW10520 (Florida) | Primary |
| Provider Name | Shannon M King |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1902048176 PECOS PAC ID: 3072665256 Enrollment ID: I20120405000108 |
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