Provider Demographics
NPI:1710384813
Name:PAPER CRANE WELLNESS SERVICES LLC
Entity Type:Organization
Organization Name:PAPER CRANE WELLNESS SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARRIE
Authorized Official - Middle Name:KYOKO
Authorized Official - Last Name:LACAYO-BENTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:904-201-9533
Mailing Address - Street 1:88 RIBERIA ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-3300
Mailing Address - Country:US
Mailing Address - Phone:904-201-9533
Mailing Address - Fax:
Practice Address - Street 1:88 RIBERIA ST
Practice Address - Street 2:SUITE 150
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-3300
Practice Address - Country:US
Practice Address - Phone:904-201-9533
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW102011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty