Healthcare Provider Details

I. General information

NPI: 1104916428
Provider Name (Legal Business Name): STEPHEN WILLIAM HENNEKA L.C.S.W.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2006
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S PONCE DE LEON BLVD STE 1
SAINT AUGUSTINE FL
32084-6013
US

IV. Provider business mailing address

1100 S PONCE DE LEON BLVD STE 1
SAINT AUGUSTINE FL
32084-6013
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7733
  • Fax: 904-829-9768
Mailing address:
  • Phone: 904-824-7733
  • Fax: 904-829-9768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW0002939
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW0002939
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: