Organization
SRC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TANYA LAKE-SMITH (MENTAL HEALTH COUNSELOR)
(678) 886-3984
Entity
Organization
Contact information
Practice address
580 ELLIS RD S, JACKSONVILLE, FL 32254-3582
(678) 886-3984
Mailing address
11993 ALEXANDRA DR, JACKSONVILLE, FL 32218-8880
(678) 886-3984
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
Other
Enumeration date
04/09/2015
Last updated
04/09/2015
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