Provider Demographics
NPI:1619032166
Name:FIRST COAST FAMILY COUNSELING, INC.
Entity Type:Organization
Organization Name:FIRST COAST FAMILY COUNSELING, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCCLENDON
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC-MA
Authorized Official - Phone:904-567-6100
Mailing Address - Street 1:PO BOX 9445
Mailing Address - Street 2:
Mailing Address - City:FLEMMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32006
Mailing Address - Country:US
Mailing Address - Phone:904-567-6100
Mailing Address - Fax:904-602-8055
Practice Address - Street 1:1718 KINGSLEY AVE STE 21
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-567-6100
Practice Address - Fax:904-602-8055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5472101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL767279900Medicaid