Healthcare Provider Details

I. General information

NPI: 1144733999
Provider Name (Legal Business Name): SANDREEA DURHAM LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/25/2020
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 WHETSTONE PL STE 205
ST AUGUSTINE FL
32086-5775
US

IV. Provider business mailing address

100 WHETSTONE PL STE 205
ST AUGUSTINE FL
32086-5775
US

V. Phone/Fax

Practice location:
  • Phone: 904-580-4386
  • Fax:
Mailing address:
  • Phone: 904-580-4386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: