MEDICARE: A SAFE PORT COUNSELING LLC

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

General Provider Information

NPI Number	:	1982380648
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A SAFE PORT COUNSELING LLC

Provider Business Mailing Address
First Line	:	4925 ATLANTIC VW
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-7139
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4925 ATLANTIC VW
Second Line	:
City	:	SAINT AUGUSTINE
State	:	FL
Zip	:	32080-7139
Country	:	US
Telephone Number	:	662-315-8357
Fax Number	:

Authorized Official
Title or Position	:	SOLE MBR
Name	:	JUSTIN FORREST DEMENT
Credential	:	LCSW
Telephone Number	:	662-315-8357

Provider Enumeration Date	:	06/26/2023
Last Update Date	:	09/12/2024

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Directions to “A SAFE PORT COUNSELING LLC ” Practice Location

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