Provider Demographics
NPI:1124988381
Name:GUARDIAN ALLIES COLLECTIVE LLC
Entity type:Organization
Organization Name:GUARDIAN ALLIES COLLECTIVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LPES
Authorized Official - Phone:904-472-6050
Mailing Address - Street 1:6565 WARD PKWY
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-3636
Mailing Address - Country:US
Mailing Address - Phone:904-472-6050
Mailing Address - Fax:854-258-5167
Practice Address - Street 1:2155 N PARK LN STE 216
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9261
Practice Address - Country:US
Practice Address - Phone:843-969-0297
Practice Address - Fax:854-258-5167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-11-12
Last Update Date:2025-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchoolGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth ServiceGroup - Multi-Specialty
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental DisabilitiesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCLP1071Medicaid