Provider Demographics
NPI:1013113554
Name:PSI SERVICES III, INC.
Entity Type:Organization
Organization Name:PSI SERVICES III, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-723-6049
Mailing Address - Street 1:3890 DUNN AVE
Mailing Address - Street 2:SUITE 1104
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-6428
Mailing Address - Country:US
Mailing Address - Phone:904-723-6049
Mailing Address - Fax:904-723-5094
Practice Address - Street 1:3890 DUNN AVE
Practice Address - Street 2:SUITE 1104
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32218-6428
Practice Address - Country:US
Practice Address - Phone:904-723-6049
Practice Address - Fax:904-723-5094
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF001251C00000X
FL251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686933596Medicaid
FL76505 1500Medicaid