Healthcare Provider Details

I. General information

NPI: 1720504517
Provider Name (Legal Business Name): DIANA BAKER BRUMMER MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2017
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 HAMPTON POINT DR STE 1
SAINT AUGUSTINE FL
32092-3054
US

IV. Provider business mailing address

PO BOX 600903
JACKSONVILLE FL
32260-0903
US

V. Phone/Fax

Practice location:
  • Phone: 904-419-7435
  • Fax:
Mailing address:
  • Phone: 904-419-7435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW16491
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: