Healthcare Provider Details

I. General information

NPI: 1215403563
Provider Name (Legal Business Name): MICHELLE FLYNN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2018
Last Update Date: 10/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 LAUREL RD E
NOKOMIS FL
34275-3212
US

IV. Provider business mailing address

4781 ANDRIS ST
NORTH PORT FL
34288-7307
US

V. Phone/Fax

Practice location:
  • Phone: 941-486-2171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14801
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: