Healthcare Provider Details

I. General information

NPI: 1407892656
Provider Name (Legal Business Name): DAVID WILLIS KENT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 10/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 ALICEA RD
LAKELAND FL
33810
US

IV. Provider business mailing address

925 S FLORAL AVE
BARTOW FL
33830
US

V. Phone/Fax

Practice location:
  • Phone: 863-680-1950
  • Fax:
Mailing address:
  • Phone: 863-534-8211
  • Fax: 863-534-8211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAP3269
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW5054
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: