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NPI Code Detail

MEDICARE: MR. SLYVING DATON BOURDEAU LCSW

MEDICARE: MR. SLYVING DATON BOURDEAU 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
1104100000XSocial Worker

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1932429339
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. SLYVING DATON BOURDEAU LCSW
Provider Business Mailing Address
First Line : PO BOX 464
Second Line :
City : PLYMOUTH
State : FL
Zip : 32768-0464
Country : US
Telephone Number : 407-470-5908
Fax Number :
Provider Business Practice Location Address
First Line : 365 WEKIVA SPRINGS RD STE 231
Second Line :
City : LONGWOOD
State : FL
Zip : 32779-3690
Country : US
Telephone Number : 407-470-5908
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2010
Last Update Date : 09/29/2015

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