Healthcare Provider Details

I. General information

NPI: 1285149823
Provider Name (Legal Business Name): JUSTIN FORREST DEMENT LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2017
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4925 ATLANTIC VW
SAINT AUGUSTINE FL
32080-7139
US

IV. Provider business mailing address

1301 PLANTATION ISLAND DR S STE 202A
SAINT AUGUSTINE FL
32080-3111
US

V. Phone/Fax

Practice location:
  • Phone: 662-315-8357
  • Fax:
Mailing address:
  • Phone: 662-315-8357
  • Fax: 904-373-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14624
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: