Healthcare Provider Details

I. General information

NPI: 1255834131
Provider Name (Legal Business Name): MICHAEL STEVEN WOHLFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ARC DR
ST AUGUSTINE FL
32084-0512
US

IV. Provider business mailing address

702 QUEEN RD
SAINT AUGUSTINE FL
32086-6540
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7249
  • Fax:
Mailing address:
  • Phone: 904-599-6987
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: