Healthcare Provider Details

I. General information

NPI: 1124336318
Provider Name (Legal Business Name): MICHAEL IMMERMAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 09/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 5TH ST
SAINT CLOUD FL
34769-2024
US

IV. Provider business mailing address

3800 5TH ST
SAINT CLOUD FL
34769-2024
US

V. Phone/Fax

Practice location:
  • Phone: 407-892-5700
  • Fax: 407-891-0091
Mailing address:
  • Phone: 407-892-5700
  • Fax: 407-891-0091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW8238
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: