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2898 Mahan Dr Ste 6 Tallahassee FL 32308-5462 | |
| (850) 656-5112 | |
| (850) 656-3802 |
| Full Name | |
|---|---|
| Speciality | Counselor |
| Location | 2898 Mahan Dr Ste 6, Tallahassee, Florida |
| Authorized Official Name and Position | Jack Richardson (CEO/CLINICAL DIRECTOR) |
| Authorized Official Contact | 8506565112 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
2724 Capital Cir Ne Ste 8 Tallahassee FL 32308-1119 Ph: (850) 656-5112 | 2898 Mahan Dr Ste 6 Tallahassee FL 32308-5462 Ph: (850) 656-5112 |
| NPI Number | 1811124613 |
|---|---|
| Provider Enumeration Date | 06/18/2009 |
| Last Update Date | 03/12/2015 |
| Medicare PECOS PAC ID | 1456490952 |
|---|---|
| Medicare Enrollment ID | O20091123000084 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811124613 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | SW 4326 (Florida) | Primary |
| 101YM0800X | Counselor - Mental Health | SW 4326 (Florida) | Secondary |
| Provider Name | Jack D Richardson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1811924509 PECOS PAC ID: 3577602135 Enrollment ID: I20091120000450 |
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