Healthcare Provider Details

I. General information

NPI: 1952451775
Provider Name (Legal Business Name): PSYCHOLOGICAL SERVICES OF ST. AUGUSTINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S PONCE DE LEON BLVD STE 1
ST AUGUSTINE FL
32084-6013
US

IV. Provider business mailing address

1100-1 SOUTH PONCE DE LEON BLVD.
ST. AUGUSTINE FL
32084
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7733
  • Fax:
Mailing address:
  • Phone: 904-824-7733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPY2444
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPY2444
License Number StateFL

VIII. Authorized Official

Name: DR. JACK MERWIN
Title or Position: OWNER
Credential: PHD.
Phone: 904-824-7733