Healthcare Provider Details

I. General information

NPI: 1891208393
Provider Name (Legal Business Name): BRYSON DALE BLACKBURN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2017
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 N 12TH AVE
ARCADIA FL
34266-8752
US

IV. Provider business mailing address

700 8TH AVE W STE 101
PALMETTO FL
34221-4737
US

V. Phone/Fax

Practice location:
  • Phone: 863-494-1242
  • Fax: 863-491-0466
Mailing address:
  • Phone: 941-776-4000
  • Fax: 941-845-4963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14904
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW14904
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: