Healthcare Provider Details

I. General information

NPI: 1740455344
Provider Name (Legal Business Name): REGINALD VILMENAY LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2008
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W BRANDON BLVD SUITE 203
BRANDON FL
33511-5104
US

IV. Provider business mailing address

220 W BRANDON BLVD SUITE 203
BRANDON FL
33511-5104
US

V. Phone/Fax

Practice location:
  • Phone: 813-892-6203
  • Fax: 813-381-3909
Mailing address:
  • Phone: 813-892-6203
  • Fax: 813-381-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW 8425
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: