Provider Demographics
NPI:1184153934
Name:PRODIGAL S D CORPORATION
Entity type:Organization
Organization Name:PRODIGAL S D CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FREDA
Authorized Official - Middle Name:
Authorized Official - Last Name:STEVENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-930-4244
Mailing Address - Street 1:9838 OLD BAYMEADOWS RD # 267
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-8101
Mailing Address - Country:US
Mailing Address - Phone:904-930-4244
Mailing Address - Fax:954-256-8140
Practice Address - Street 1:9521 SHELLIE RD STE 13
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6174
Practice Address - Country:US
Practice Address - Phone:904-930-4244
Practice Address - Fax:954-256-8140
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRODIGAL S D CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty