Healthcare Provider Details

I. General information

NPI: 1366563728
Provider Name (Legal Business Name): PAMELA JO GROVE-GOUGELMAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 OCEAN OAKS DR
INDIALANTIC FL
32903-2749
US

IV. Provider business mailing address

350 OCEAN OAKS DR
INDIALANTIC FL
32903-2749
US

V. Phone/Fax

Practice location:
  • Phone: 954-547-4883
  • Fax:
Mailing address:
  • Phone: 954-547-4883
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8383
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: