Healthcare Provider Details

I. General information

NPI: 1659072866
Provider Name (Legal Business Name): ANNIE GRACE HARDWICK LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3955 LEWIS SPEEDWAY
ST AUGUSTINE FL
32084-8611
US

IV. Provider business mailing address

355 LA MANCHA DR
ST AUGUSTINE FL
32086-0398
US

V. Phone/Fax

Practice location:
  • Phone: 904-209-2241
  • Fax:
Mailing address:
  • Phone: 904-704-0117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH21390
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: