Healthcare Provider Details

I. General information

NPI: 1932429339
Provider Name (Legal Business Name): SLYVING DATON BOURDEAU LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 07/03/2026
Certification Date: 07/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9401 W COLONIAL DR STE 726
OCOEE FL
34761-6811
US

IV. Provider business mailing address

PO BOX 464
PLYMOUTH FL
32768-0464
US

V. Phone/Fax

Practice location:
  • Phone: 407-470-5908
  • Fax:
Mailing address:
  • Phone: 407-470-5908
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW11513
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: