Healthcare Provider Details

I. General information

NPI: 1417193418
Provider Name (Legal Business Name): JUSTIN A DARIENZO PSYD ABPP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2008
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4651 SALISBURY RD SUITE 532
JACKSONVILLE FL
32256-6107
US

IV. Provider business mailing address

11197 TURNBRIDGE DR
JACKSONVILLE FL
32256-2337
US

V. Phone/Fax

Practice location:
  • Phone: 904-536-5312
  • Fax:
Mailing address:
  • Phone: 904-536-5312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License NumberPY7397
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License NumberPY7397
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY7397
License Number StateFL

VIII. Authorized Official

Name: DR. JUSTIN ANTHONY D'ARIENZO
Title or Position: FOUNDER AND CEO
Credential: PSY.D., ABPP
Phone: 904-536-5312