Healthcare Provider Details

I. General information

NPI: 1427276997
Provider Name (Legal Business Name): DAVID M FEAZELL PHD P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 03/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 CATHEDRAL PL SUITE 412
ST AUGUSTINE FL
32084-4473
US

IV. Provider business mailing address

24 CATHEDRAL PL SUITE 412
ST AUGUSTINE FL
32084-4473
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-9975
  • Fax: 904-824-9943
Mailing address:
  • Phone: 904-824-9975
  • Fax: 904-824-9943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPY2187
License Number StateFL

VIII. Authorized Official

Name: DAVID M FEAZELL
Title or Position: PSYCHOLOGIST
Credential: PH.D.
Phone: 904-824-9975