Healthcare Provider Details

I. General information

NPI: 1619378908
Provider Name (Legal Business Name): SANTRICOA NELSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 E WASHINGTON ST APT A
MINNEOLA FL
34715-9227
US

IV. Provider business mailing address

4227 WORTHINGTON PL
MASCOTTE FL
34753-9742
US

V. Phone/Fax

Practice location:
  • Phone: 407-734-3338
  • Fax: 407-377-7517
Mailing address:
  • Phone: 321-356-4736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16155
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberN425792713420
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: