Healthcare Provider Details

I. General information

NPI: 1114467834
Provider Name (Legal Business Name): LOUIS R. LOTHMAN FL. LICENSED MARRIAG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2017
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3734 SAN VISCAYA DR.
JACKSONVILLE FL
32217
US

IV. Provider business mailing address

3734 SAN VISCAYA DR.
JACKSONVILLE FL
32217
US

V. Phone/Fax

Practice location:
  • Phone: 904-631-9198
  • Fax:
Mailing address:
  • Phone: 904-631-9198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number3181
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMT1294
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: