Healthcare Provider Details

I. General information

NPI: 1972657153
Provider Name (Legal Business Name): MARK S FLYNN PSY.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1543 KINGSLEY AVE SUITE 18A
ORANGE PARK FL
32073-4535
US

IV. Provider business mailing address

1543 KINGSLEY AVE SUITE 18A
ORANGE PARK FL
32073-4535
US

V. Phone/Fax

Practice location:
  • Phone: 904-269-3324
  • Fax: 904-264-2302
Mailing address:
  • Phone: 904-269-3324
  • Fax: 904-264-2302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 7164
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY7164
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: