Healthcare Provider Details

I. General information

NPI: 1376873398
Provider Name (Legal Business Name): SUE ANN WEBER PH. D, L.M.H.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6261 DUPONT STATION CT
JACKSONVILLE FL
32217-2567
US

IV. Provider business mailing address

6261 DUPONT STATION CT
JACKSONVILLE FL
32217-2567
US

V. Phone/Fax

Practice location:
  • Phone: 904-394-5751
  • Fax: 904-448-0349
Mailing address:
  • Phone: 904-394-5751
  • Fax: 904-448-0349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH8614
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: