Healthcare Provider Details

I. General information

NPI: 1174268916
Provider Name (Legal Business Name): DUSTIN BLEND LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DEERFIELD PRESERVE BLVD
ST AUGUSTINE FL
32086-5966
US

IV. Provider business mailing address

100 DEERFIELD PRESERVE BLVD
ST AUGUSTINE FL
32086-5966
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-0814
  • Fax:
Mailing address:
  • Phone: 954-885-9500
  • Fax: 904-829-0814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW18583
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: