Healthcare Provider Details

I. General information

NPI: 1366558389
Provider Name (Legal Business Name): CYNTHIA GEDDES LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 02/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 EXECUTIVE WAY SUITE 113
PONTE VEDRA BEACH FL
32082-2715
US

IV. Provider business mailing address

100 EXECUTIVE WAY SUITE 113
PONTE VEDRA BEACH FL
32082-2715
US

V. Phone/Fax

Practice location:
  • Phone: 904-273-6747
  • Fax:
Mailing address:
  • Phone: 904-273-6747
  • Fax: 904-273-6861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6257
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: