Provider Demographics
NPI:1528790292
Name:PRISM COMMUNITY MENTAL HEALTH, LLC
Entity type:Organization
Organization Name:PRISM COMMUNITY MENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, ACSW
Authorized Official - Phone:904-654-3275
Mailing Address - Street 1:351 CROSSING BLVD APT 911
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-6241
Mailing Address - Country:US
Mailing Address - Phone:904-654-3275
Mailing Address - Fax:
Practice Address - Street 1:351 CROSSING BLVD APT 911
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-6241
Practice Address - Country:US
Practice Address - Phone:904-654-3275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)