Provider Demographics
NPI:1598740896
Name:RITA, JACQUELINE (LMHC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:RITA
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:
Other - Last Name:RITA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMHC
Mailing Address - Street 1:955 MARIE CIR
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32176-4143
Mailing Address - Country:US
Mailing Address - Phone:401-431-9870
Mailing Address - Fax:
Practice Address - Street 1:955 MARIE CIR
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32176-4143
Practice Address - Country:US
Practice Address - Phone:401-431-9870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00222101YM0800X
FL11788101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI412090OtherBLUE CHIP
RI27972-1OtherBLUE CROSS
RIJR36967Medicaid