Healthcare Provider Details

I. General information

NPI: 1215424924
Provider Name (Legal Business Name): NATE MAW M.A. CAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 S HIGHWAY 29
CANTONMENT FL
32533-5808
US

IV. Provider business mailing address

2420 S HIGHWAY 29
CANTONMENT FL
32533-5808
US

V. Phone/Fax

Practice location:
  • Phone: 850-968-3565
  • Fax:
Mailing address:
  • Phone: 850-968-3565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADC-008636-2015
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: