Provider Demographics
NPI:1700369857
Name:THERESA COUNCIL LLC
Entity Type:Organization
Organization Name:THERESA COUNCIL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:COUNCIL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-355-6864
Mailing Address - Street 1:2815 MELSON AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32254-1853
Mailing Address - Country:US
Mailing Address - Phone:904-355-6864
Mailing Address - Fax:
Practice Address - Street 1:2815 MELSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-1853
Practice Address - Country:US
Practice Address - Phone:904-355-6864
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-13
Last Update Date:2019-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
No251K00000XAgenciesPublic Health or Welfare
No251V00000XAgenciesVoluntary or Charitable
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Single Specialty