Provider Demographics
NPI:1770955254
Name:BEACHES BEHAVIORAL HEALTH LLC
Entity type:Organization
Organization Name:BEACHES BEHAVIORAL HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:J
Authorized Official - Last Name:ROTELLA
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:610-331-2645
Mailing Address - Street 1:6652 EPPING FOREST WAY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-2648
Mailing Address - Country:US
Mailing Address - Phone:904-280-0790
Mailing Address - Fax:904-395-9181
Practice Address - Street 1:3733 UNIVERSITY BLVD W STE 209
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-2103
Practice Address - Country:US
Practice Address - Phone:904-543-6055
Practice Address - Fax:904-395-9181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-23
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW130841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty