Healthcare Provider Details

I. General information

NPI: 1184969008
Provider Name (Legal Business Name): VERNON RICARDO WASHINGTON M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2012
Last Update Date: 12/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 S DIXIE HWY
ST AUGUSTINE FL
32084-0317
US

IV. Provider business mailing address

67 S DIXIE HWY
ST AUGUSTINE FL
32084-0317
US

V. Phone/Fax

Practice location:
  • Phone: 904-429-7573
  • Fax: 904-547-2731
Mailing address:
  • Phone: 904-429-7573
  • Fax: 904-547-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH10523
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: