Healthcare Provider Details

I. General information

NPI: 1689766925
Provider Name (Legal Business Name): LUNISE LUC MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3027 SAN DIEGO RD
JACKSONVILLE FL
32207-3691
US

IV. Provider business mailing address

3027 SAN DIEGO RD
JACKSONVILLE FL
32207-3691
US

V. Phone/Fax

Practice location:
  • Phone: 904-493-7744
  • Fax: 904-348-2818
Mailing address:
  • Phone: 904-493-7744
  • Fax: 904-348-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberISW3895
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: