Healthcare Provider Details

I. General information

NPI: 1316577331
Provider Name (Legal Business Name): GRACIA HAYGOOD LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2020
Last Update Date: 01/17/2020
Certification Date: 01/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5421 US HWY 98 S
HIGHLAND CITY FL
33846
US

IV. Provider business mailing address

1815 CRYSTAL LAKE DR
LAKELAND FL
33801-5979
US

V. Phone/Fax

Practice location:
  • Phone: 863-701-7373
  • Fax:
Mailing address:
  • Phone: 863-709-9392
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW16038
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: