Prodigal S D Corporation

Primary specialty

Addiction (Substance Use Disorder) CounselorTaxonomy code 101YA0400X

Legal business name

PRODIGAL S D CORPORATION

Doing business as

Prodigal Kids

Practice address

9521 Shellie Rd Ste 13
Jacksonville, FL 32257-6174

Phone

(904) 930-4244

Fax

(954) 256-8140

NPI assigned

Jun 6, 2017

Organization subpart

Yes

Parent organization

PRODIGAL S D CORPORATIONAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Freda Stevens

Title

Executive Director

Phone

(904) 930-4244

Specialties & licenses 5

Addresses

Other names 1

• Prodigal Kids Doing business as

Part of

Prodigal S D Corporation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1496707200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1496707200000",
    "number": "1184153934",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "9838 OLD BAYMEADOWS RD # 267",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322568101",
            "telephone_number": "904-930-4244",
            "fax_number": "954-256-8140"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "9521 SHELLIE RD STE 13",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322576174",
            "telephone_number": "904-930-4244",
            "fax_number": "954-256-8140"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRODIGAL S D CORPORATION",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "PRODIGAL S D CORPORATION",
        "enumeration_date": "2017-06-06",
        "last_updated": "2017-06-06",
        "status": "A",
        "authorized_official_last_name": "STEVENS",
        "authorized_official_first_name": "FREDA",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "904-930-4244"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Mental Health",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YP1600X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Pastoral",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "101YP2500X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TP2701X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Group Psychotherapy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Prodigal Kids",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Charles Daniel Procter Sr., MD
• Gary Ray Proctor, M.D.
• Jessica Proctor, DMD
• Lauren Marie Proctor
• Tatiyana Proctor
• Joshua Brendan Proemsey, M.D.
• Professional Care Services by MMLG
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• Professional Dental Alliance of Jacksonville Lem TRNR, PLLC
• Professional Dental Alliance of Jacksonville Ozark, PLLC

• Addiction (Substance Use Disorder) Counselor in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Addiction (Substance Use Disorder) Counselor in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 6, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.