Healthcare Provider Details

I. General information

NPI: 1861830028
Provider Name (Legal Business Name): MISS MORGAN LACY GAWRILUK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2013
Last Update Date: 09/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3208 GULF BREEZE PKWY
GULF BREEZE FL
32563-3350
US

IV. Provider business mailing address

1406 HAYS ST SUIT 8
TALLAHASSEE FL
32301-2833
US

V. Phone/Fax

Practice location:
  • Phone: 800-676-5130
  • Fax:
Mailing address:
  • Phone: 850-521-0242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: