Provider Demographics
NPI:1841337060
Name:THERAPY SOURCE, LLC
Entity type:Organization
Organization Name:THERAPY SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:DRISCOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-396-1462
Mailing Address - Street 1:3311 BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-3704
Mailing Address - Country:US
Mailing Address - Phone:904-396-1462
Mailing Address - Fax:904-396-1199
Practice Address - Street 1:3311 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-3704
Practice Address - Country:US
Practice Address - Phone:904-396-1462
Practice Address - Fax:904-396-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL891337400Medicaid