Healthcare Provider Details

I. General information

NPI: 1366188773
Provider Name (Legal Business Name): ZULEIKA FUENTES PINTO CLINICAL SOCIAL WORK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14300 FANG DR
JACKSONVILLE FL
32218-7933
US

IV. Provider business mailing address

829 MILES DR
PANAMA CITY FL
32404-8431
US

V. Phone/Fax

Practice location:
  • Phone: 850-855-6123
  • Fax:
Mailing address:
  • Phone: 850-855-6123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number15619
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: