Provider Demographics
NPI:1275887598
Name:ATLANTIC FAMILY INSTITUTE
Entity Type:Organization
Organization Name:ATLANTIC FAMILY INSTITUTE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HERBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MED, EDS
Authorized Official - Phone:904-247-5669
Mailing Address - Street 1:808 3RD ST
Mailing Address - Street 2:STE C
Mailing Address - City:NEPTUNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32266-5081
Mailing Address - Country:US
Mailing Address - Phone:904-247-5669
Mailing Address - Fax:
Practice Address - Street 1:808 3RD ST
Practice Address - Street 2:STE C
Practice Address - City:NEPTUNE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32266-5081
Practice Address - Country:US
Practice Address - Phone:904-247-5669
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT0001341106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006678800Medicaid