Healthcare Provider Details

I. General information

NPI: 1316112709
Provider Name (Legal Business Name): MGW INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 03/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 PASEO REYES DR
ST AUGUSTINE FL
32095-8464
US

IV. Provider business mailing address

350 PASEO REYES DR
ST AUGUSTINE FL
32095-8464
US

V. Phone/Fax

Practice location:
  • Phone: 904-777-8777
  • Fax: 904-777-8700
Mailing address:
  • Phone: 904-777-8777
  • Fax: 904-777-8700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY6360
License Number StateFL

VIII. Authorized Official

Name: DR. SHARON L SCHULMAN
Title or Position: VP
Credential: PH.D.
Phone: 904-436-6032