Healthcare Provider Details

I. General information

NPI: 1508886615
Provider Name (Legal Business Name): KATHLEEN E. ABBOTT MSW, LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 09/14/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2155 OLD MOULTRIE RD SUITE 110
ST AUGUSTINE FL
32086-5102
US

IV. Provider business mailing address

2155 OLD MOULTRIE RD SUITE 110
ST AUGUSTINE FL
32086-5102
US

V. Phone/Fax

Practice location:
  • Phone: 904-797-5680
  • Fax: 904-797-5681
Mailing address:
  • Phone: 904-797-5680
  • Fax: 904-797-5681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH0001323
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: