Provider Demographics
NPI:1407306897
Name:VILLAGE COUNSELING CENTER OF GAINESVILLE, INC.
Entity Type:Organization
Organization Name:VILLAGE COUNSELING CENTER OF GAINESVILLE, INC.
Other - Org Name:VILLAGE COUNSELING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:DYLAN
Authorized Official - Last Name:EDELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EDS, LMHC
Authorized Official - Phone:352-373-8189
Mailing Address - Street 1:3919 W NEWBERRY RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32607-4828
Mailing Address - Country:US
Mailing Address - Phone:352-373-8189
Mailing Address - Fax:352-373-8190
Practice Address - Street 1:3919 W NEWBERRY ROAD
Practice Address - Street 2:SUITE 5
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607-4848
Practice Address - Country:US
Practice Address - Phone:352-373-8189
Practice Address - Fax:352-373-8190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-10
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH4473101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766664100Medicaid