Provider Demographics
NPI:1841686433
Name:SRC
Entity type:Organization
Organization Name:SRC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH COUNSELOR
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:LAKE-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-886-3984
Mailing Address - Street 1:11993 ALEXANDRA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-8880
Mailing Address - Country:US
Mailing Address - Phone:678-886-3984
Mailing Address - Fax:
Practice Address - Street 1:580 ELLIS RD S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32254-3582
Practice Address - Country:US
Practice Address - Phone:678-886-3984
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health