Healthcare Provider Details

I. General information

NPI: 1003533423
Provider Name (Legal Business Name): ALTAGRACE K SOUVERAIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4120 US HIGHWAY 98 N
LAKELAND FL
33809-3854
US

IV. Provider business mailing address

1324 LAKELAND HILLS BLVD
LAKELAND FL
33805-4543
US

V. Phone/Fax

Practice location:
  • Phone: 863-687-1222
  • Fax:
Mailing address:
  • Phone: 863-687-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW20568
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: