Organization
COMMUNITY VICTORY FAMILY SERVICES, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MIRANDA FAULKNER-SMITH (OFFICER)
(813) 440-2741
Entity
Organization
Contact information
Practice address
32750 PENNSYLVANIA AVE, SAN ANTONIO, FL 33576-7096
(813) 440-2741
(813) 388-4490
Mailing address
12231 MAIN ST UNIT 1196, SAN ANTONIO, FL 33576-7253
(813) 440-2741
(813) 388-4490
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
MH13166
FL
101YP2500X
Professional Counselor
0701005890
VA
101YP2500X
Professional Counselor
Primary
MH13166
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
014618400
—
FL
01
—
1366851875
NPI
—
Enumeration date
10/02/2017
Last updated
03/17/2018
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