MEDICARE: MS. EMILY MIRA FOX LCSW

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	1041C0700X	Clinical Social Worker	7377	FL

General Provider Information

NPI Number	:	1770179749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. EMILY MIRA FOX LCSW

Provider Business Mailing Address
First Line	:	777 REMBRANDT AVE
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-5033
Country	:	US
Telephone Number	:	904-547-9915
Fax Number	:

Provider Business Practice Location Address
First Line	:	777 REMBRANDT AVE
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-5033
Country	:	US
Telephone Number	:	904-547-9915
Fax Number	:

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

Provider Enumeration Date	:	12/14/2020
Last Update Date	:	12/14/2020

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