Provider Demographics
NPI:1760932529
Name:SOUTHSIDE COUNSELING BIOFEEDBACK & STRESS MANAGEMENT CENTER, INC
Entity Type:Organization
Organization Name:SOUTHSIDE COUNSELING BIOFEEDBACK & STRESS MANAGEMENT CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:G
Authorized Official - Last Name:STANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-396-9144
Mailing Address - Street 1:4943 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-4802
Mailing Address - Country:US
Mailing Address - Phone:904-396-9144
Mailing Address - Fax:
Practice Address - Street 1:4943 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-4802
Practice Address - Country:US
Practice Address - Phone:904-396-9144
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 1539101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty