Healthcare Provider Details

I. General information

NPI: 1629851233
Provider Name (Legal Business Name): DUSTIN LEE PRICE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2023
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11975 STONE PINE ST
RIVERVIEW FL
33569-5640
US

IV. Provider business mailing address

11975 STONE PINE ST
RIVERVIEW FL
33569-5640
US

V. Phone/Fax

Practice location:
  • Phone: 941-376-0011
  • Fax:
Mailing address:
  • Phone: 941-376-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC61465267
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: