Healthcare Provider Details

I. General information

NPI: 1265566079
Provider Name (Legal Business Name): MICHELLE JEANNETTE DUNN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MICHELLE DONATELLO LCSW

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 07/31/2020
Certification Date: 07/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 FOX WATER TRL
SAINT AUGUSTINE FL
32086
US

IV. Provider business mailing address

443 FOX WATER TRL
SAINT AUGUSTINE FL
32086
US

V. Phone/Fax

Practice location:
  • Phone: 904-671-6955
  • Fax: 781-874-8744
Mailing address:
  • Phone: 904-671-6955
  • Fax: 781-874-8744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW16097
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122477
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: