Healthcare Provider Details

I. General information

NPI: 1871943878
Provider Name (Legal Business Name): STEPHEN CHASE DSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2016
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 MDOS/ SGOW 1370 SOUTH PATRICK DR
PATRICK AFB FL
32925
US

IV. Provider business mailing address

45 MDOS/ SGOW 1370 SOUTH PATRICK DR
PATRICK AFB FL
32925
US

V. Phone/Fax

Practice location:
  • Phone: 321-494-8171
  • Fax: 321-494-8074
Mailing address:
  • Phone: 321-494-8171
  • Fax: 321-494-8074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11392
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: