Provider Demographics
NPI:1326559097
Name:AUTHENTICALLY YOU, LLC
Entity Type:Organization
Organization Name:AUTHENTICALLY YOU, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:904-629-1565
Mailing Address - Street 1:109 NATURE WALK PKWY UNIT 104
Mailing Address - Street 2:
Mailing Address - City:SAINT AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-5065
Mailing Address - Country:US
Mailing Address - Phone:904-629-1565
Mailing Address - Fax:904-562-3465
Practice Address - Street 1:109 NATURE WALK PKWY UNIT 104
Practice Address - Street 2:
Practice Address - City:SAINT AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32092-5065
Practice Address - Country:US
Practice Address - Phone:904-629-1565
Practice Address - Fax:904-562-3465
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-20
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH13243251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health