MEDICARE: MR. DAVID LEROY HACKNEY L.M.H.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	MH22	FL

General Provider Information

NPI Number	:	1407946726
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID LEROY HACKNEY L.M.H.C.

Provider Business Mailing Address
First Line	:	1100 S PONCE DE LEON BLVD STE 1
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32084-6013
Country	:	US
Telephone Number	:	904-824-7733
Fax Number	:	904-829-9768

Provider Business Practice Location Address
First Line	:	1100 S PONCE DE LEON BLVD STE 1
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32084-6013
Country	:	US
Telephone Number	:	904-824-7733
Fax Number	:	904-829-9768

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/15/2006
Last Update Date	:	07/08/2007

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