Healthcare Provider Details

I. General information

NPI: 1356650808
Provider Name (Legal Business Name): PAUL FUGELSANG
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2010
Last Update Date: 10/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 ESTEY ST
ST AUGUSTINE FL
32084-2843
US

IV. Provider business mailing address

18 ESTEY ST
ST AUGUSTINE FL
32084-2843
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-3009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH10387
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: