Provider Demographics
NPI:1538676671
Name:NORTH FLORIDA CHILDREN'S MENTAL WELLNESS, LLC
Entity Type:Organization
Organization Name:NORTH FLORIDA CHILDREN'S MENTAL WELLNESS, LLC
Other - Org Name:SOUTHEASTERN PSYCHOLOGICAL SERVICES FOR CHILDREN & ADOLESCENTS, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-841-9836
Mailing Address - Street 1:143 FLAMINGO CT
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:FL
Mailing Address - Zip Code:32344-0892
Mailing Address - Country:US
Mailing Address - Phone:850-841-9836
Mailing Address - Fax:
Practice Address - Street 1:201 BOB WALLACE AVE SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-3810
Practice Address - Country:US
Practice Address - Phone:256-642-7400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-10
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health