Provider Demographics
NPI:1902363351
Name:PRISTUPA, MORGAN LOUISE
Entity Type:Individual
Prefix:
First Name:MORGAN
Middle Name:LOUISE
Last Name:PRISTUPA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7932 ALTAMA RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-9315
Mailing Address - Country:US
Mailing Address - Phone:904-318-5955
Mailing Address - Fax:
Practice Address - Street 1:13121 ATLANTIC BLVD STE 200
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-0102
Practice Address - Country:US
Practice Address - Phone:904-491-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-19-77952106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician