Healthcare Provider Details

I. General information

NPI: 1679961403
Provider Name (Legal Business Name): KASSANDRA MCCUNE ENTERPRISES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2015
Last Update Date: 01/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

88 RIBERIA ST SUITE 150
SAINT AUGUSTINE FL
32084-3300
US

IV. Provider business mailing address

38 GRANT ST
SAINT AUGUSTINE FL
32084-2746
US

V. Phone/Fax

Practice location:
  • Phone: 904-392-9188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH10498
License Number StateFL

VIII. Authorized Official

Name: KASSANDRA SHUGARS MCCUNE
Title or Position: PRESIDENT
Credential:
Phone: 904-392-9188